Project I See You Immersion Trip Application

Project I See You Immersion Trip Application

Thank you for your interest in Project I See You’s work in the Dominican Republic. We are so grateful for the story that is being written in partnership with the women of La Victoria. Please take a moment to review our mission statement and values as an organization on our website, www.projectiseeyou.org and please complete this application prior to the first pre-trip meeting.
Full Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail*
example@example.com
Cell Number*
Home or Work Number, if different
Please enter a valid phone number.
How did you hear about Project I See You?
Why are you interested in an Immersion trip at this time?
What experiences have you had, if any, that will contribute to your work with us in a developing country?
What concerns/hesitations do you have about traveling to the Dominican Republic?
What are your expectations for a trip with Project I See You?
How will you uniquely benefit a team working in this context?
How would you describe your spiritual life currently?
Please use this space to add anything else you would like us to know about you.

Project I See You Acknowledgement of Risk, Release of Liability and Photography Permission

April 2022 Trip to the D.R.

If the participant is an adult, participant agrees to the following:

I agree to waive any and all rights and claims for damages that I, or my spouse may have against Project I See You and its agents, employees, and representatives for any and all injury, damage, or loss sustained by the participants arising directly or indirectly out of participation in this ministry.

I further agree that, in the event that I should make any claim against Project I See You for damage, injury, or loss arising directly or indirectly out of the volunteer involvement, I will personally indemnify, defend and hold harmless the ministry and its agents, employees, and representatives against any and all such injury, damage, or loss. I acknowledge there is a risk in volunteering to go and minister in a third world country and I assume any such risk.

I affirm that I have the right to authorize and agree to the foregoing. I have read and understand this agreement and have willingly placed my signature below as evidence of my acceptance of all the conditions contained herein.

I grant to Project I See You, its representatives and employees the right to take photographs and video of me and my property in connection with my participation. I agree that Project I See You may use such photographs and video of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising and web content, its assigns and transferees to copyright, use and publish the same in print and electronically.

I have carefully read this agreement and fully understand its contents. I am aware that this is a release of liability and a contract between myself and Project I See You. By signing below, I acknowledge I have read and that I agree to the terms stated above.
Signature

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Printed Name
Date

MonthDayYear
Date

Primary person to be notified in case of an emergency:*

First NameLast Name
Relationship

RelativeFriendOther
Emergency Contact Cell Phone*
Please enter a valid phone number.
Emergency Contact Other Phone
Please enter a valid phone number.
Emergency Contact Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Email*
example@example.com

Secondary person to be notified in case of an emergency:*

First NameLast Name
Relationship

RelativeFriendOther
Secondary Emergency Contact Cell Phone*
Please enter a valid phone number.
Secondary Emergency Contact Other Phone
Please enter a valid phone number.
Secondary Emergency Contact Email*
example@example.com
Secondary Emergency Contact Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Medical Insurance Information:

ProviderPhone Number
Contact personID or Ref #
List any medications you take routinely and provide details:
Details of any medical/mobility/mental health conditions that affect you currently or in the recent past.
List any allergies that affect you and provide details:
Any other information that emergency personnel should be aware of:
The information requested on this form will be treated as confidential and referred to only in the case of an emergency. In the event of a medical emergency, this information will be available to Project I See You trip leaders and emergency personnel.

Please insure that your information is accurate and up to date.
In the case of an emergency, I authorize this information to be released to emergency personnel. I also agree that my emergency contacts be notified in case of an emergency.

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Printed Name
MonthDayYear
Date
Should be Empty: