Name *

As it appears on your passport or state-issued ID

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone Number *

(###)

###

####

Gender *

Male

Female

Date of Birth *

MM

DD

YYYY

Date of Issue *

MM

DD

YYYY

Date of Expiration *

MM

DD

YYYY

In Case of Emergency Notify *

First Name

Last Name

Phone Number *

(###)

###

####

References *

Please provide one pastoral and one co-worker reference (preferably, people who could speak to your: spitirual maturity, emotional maturity and social maturity)

First Name

Last Name

Phone *

(###)

###

####

Name *

First Name

Last Name

Phone *

(###)

###

####

Regular Physician *

First Name

Last Name

Phone *

(###)

###

####

Participation Agreement *

I agree to release, discharge, and hold harmeless LHl, its employees, agents and members from any and all claims or demands due to personal injury, illness, or death as well as any and all property damage sustained of any nature which may be incurred by me, whether in foreign or domestic territory, while participating in the above described event or activity. I also agree to be directed by and responsible to the designated church leadership for the project. Further, I agree to hold harmless and to indemnify LHI ,as well as, its employees, agents, or members for any liability or expenses sustained by the Church as a result of my participation. I hereby authorize LHI or its representative to initiate any medically necessary care on my behalf in the event of my incapability to present myself for such care and agree to be financially responsible to any care provider and authorize the release of any necessary medical or insurance related information pertinent to the circunstances.

I agree

I will participate in each training meeting or make up the meeting I miss for possible unavoidable reasons. *

I agree

I will read through the manual and guidelines provided by LHI thoroughly as I prepare for this trip. *

I agree

I believe that through prayer and wise counsel, God has directed me to be a participant on this trip. Therefore, I will be a person of faith as well as faithfulness, believing that as I am diligent to uphold the the commitment I am making to this trip, God will be faithful in His to provide and prepare me for what He has for me. *

I agree

I will (by faith!) meet all the financial obligations of this trip, regardless of support raising shortfalls. *

I agree

I agree to abide by the team policies of Living Hope and by the rules, policies, and project leadership of Living Hope in Zambia, even though I may not totally agree with them in every situation. *

I agree

The information on this form and attached forms is correct to the best of my knowledge. I authorize any references to release all such information to assist in evaluation. I release all references from liability for any damage that may result from furnishing such evaluations to LHI and I waive any right that references and appropriate government agencies. *

I agree

Signature *

First Name

Last Name

Today's Date *

MM

DD

YYYY