Rafiki Trip Application

Rafiki Trip Application

* Please submit completed application, $50 fee and passport photo ID* Each traveler needs to submit an application*
Name as it Appears in Passport *

Prefix First Name Middle Name Last Name
Best Contact Number *

Area Code Phone Number
Mailing Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
E-mail *
Verify Email *
Are you traveling with a family member or a friend? If so, specify nature of relationship *
Dates of Trip *
Gender *
Social Security Number *
Date of Birth *
Passport Number *
Passport Expiration Date *
T-Shirt Size (Unisex) *
Occupation, Talents, Skills *
International Travel Experience *
Why are you interested in Rafiki trip *
From Whom/How did you learn about Rafiki trip *
I have never been convicted of, pled guilty or no contest to a crime other than a minor traffic violation. Yes / No Explain if No *
I have not been and am not presently under charges for any criminal offense. *
YES/NO
I authorize Rafiki to conduct a Criminal and Sex Offender background search. *
YES/NO
In Case of an Emergency, Notify
First Name Last Name Relationship Area Code Phone Number Email Street Address Address Line 2 City State Zip
Insurance Company _________________________Policy & Group Number: ___________________
Phone Number _____________________Name of Beneficiary: _______________________________
Name of Your Physician: _________________________________ Area Code Phone Number
Do you take any medications? Yes/No. Please list all *
Have you had a recent illness (in the last year)? Yes / No / When? Explain *
Do you have any allergies to food, drugs, insect bites or stings? Yes/ No If yes, what? *
Do you have any chronic medical conditions? Yes / No Explain: *
Immunizations and Dates (if applicable): *
Do you have any physical limitations or disabilities that would affect you in conditions such as extreme heat or cold, high elevation, limited food choices, etc.? Yes / No Explain: *
Have you ever been treated or hospitalized for a mental or emotional condition? Yes / No Explain *
I acknowledge that participation in the above trip involves risk to the Participant (and to Participant’s parents or guardians if Participant is a minor), and may result in various types of injury. In consideration for the opportunity to participate in the above trip, the Participant (or parent/guardian if Participant is a minor) acknowledges and accepts the risks of injury associated with participation in the trip. I understand that Rafiki Africa, its agents, employees, volunteers, or any other representatives (collectively included hereinafter in the term “Trip Sponsor”) assume no liability for any personal harm or illness or for loss or damage of any property that may come to me while serving as a mission volunteer, and I, my heirs, and my personal representatives and assigns, hereby absolve the Trip Sponsor and hold them harmless from any claim or demand that I, my heirs, my personal representatives or assigns might conceivably assert for any such harm, illness, loss or damage. I confirm that the information provided by me on this application is correct. I understand Trip Sponsor may use any images or videos I take while on the mission. I approve the sharing of my contact information with others participating on this trip. I also purpose to partake in required pre and post mission training. I intend to be legally bound by this statement.
Signature: Participant or parent/guardian of participant if a minor *
Signature Date
Signature: Second parent/guardian of participant if a minor *
Signature Date
Passport Photo
Should be Empty:

Rafiki Trip Application

In Case of an Emergency, Notify