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Emergency Contact Information Form

Volunteer Emergency Contact Information

Please provide us with the name and contact information of the person we should contact in case of an emergency.

Name :

___________________________________________

Relationship :

___________________________________________

Daytime Phone :

___________________________________________

Evening Phone :

___________________________________________

Mobile nubmer :

___________________________________________

Home address :

___________________________________________

Email :

___________________________________________

Additional Information :

___________________________________________
___________________________________________
___________________________________________
___________________________________________
___________________________________________
___________________________________________

Please return release prior to Volunteer Trip.
God's Chosen Ones Ministry
P.O. Box 910501
Saint George, Utah 84791
Attn: Mission Trips
Fax: 717-754-5750
info@gcomintl.org

Medical Information Form

Please provide us with the following medical information in case of an emergency.

Name :

___________________________________________

Exiting Medical Conditions :

___________________________________________

Allergies :

___________________________________________

List any medication you are currently taking :

___________________________________________

Doctors Name :

___________________________________________

Phone Number of Doctor :

___________________________________________

Insurance Information :

___________________________________________

Any addition information that would be helpful in a Medical Emergency :

___________________________________________
___________________________________________
___________________________________________

Please return release prior to Volunteer Trip.
God's Chosen Ones Ministry
P.O. Box 910501
Saint George, Utah 84791
Attn: Mission Trips
Fax: 717-754-5750
info@gcomintl.org

Acknowledgment Page

A mission trip can be a very rewarding experience. However, if a volunteer goes to a third world country unprepared it can make for an unpleasant experience. It is vital that all volunteers read and acknowledge that they understand the risks, requirements and expectations of travel to Haiti.

After reading the mission packet please sign the following document and return to the Mission Director along with the release of liability, emergency contact information and medical information form. Please also send a color copy of your passport and a copy of your medical insurance card.

Thank you.
God's Chosen Ones Ministry, Board of Directors

The undersigned hereby acknowledges, receiving this Mission packet, and acknowledges that they have read and understand all requirements and expectations listed herein.

Name :

___________________________________________

Signature :

___________________________________________

Date signed :

___________________________________________

Please return release prior to Volunteer Trip.
God's Chosen Ones Ministry
P.O. Box 910501
Saint George, Utah 84791
Attn: Mission Trips
Fax: 717-754-5750
info@gcomintl.org

Mission Trip Application

God’s Chosen Ones Ministry Mission Trip Application

Personal Information

Name :

___________________________________________

Address :

___________________________________________

Phone :

___________________________________________

Email :

___________________________________________

Marital Status :

___________________________________________

Date of Birth :

_______________________ ( DD/MM/YYYY)

Health Information

Describe your general health condition :

___________________________________________

Are you taking any medication? If so, what? :

___________________________________________

Allergies :

___________________________________________

Blood type :

___________________________________________

Family Physician :

___________________________________________

Medical Insurance Company for trip :

___________________________________________

Medical Insurance Contact :

___________________________________________

Emergency Contact Person :

___________________________________________

Emergency Contact Phone :

___________________________________________

Relationship :

___________________________________________

Travel Information

Have you ever been to Haiti before? :

Yes No

Passport Number :

___________________________________________

How will you be arriving to Miami? Airline :

___________________________________________

Flight number :

___________________________________________

Arrival Time :

___________________________________________

Do you want to book your own ticket from
Miami to PAP? :

Yes No