THAILAND STM APPLICATION FORM (ENG)

Medical Info. & Emergency Release Form

Please complete the following information in case of emergency. In cases where it's not applicable, you can put "N/A" or "None."
Blood Type*
Any physical handicaps, disabilities, allergies, or other conditions that may interfere with missionary work? *
Are you allergic to peanuts or fish?*
Please list any other conditions (i.e. diabetes)
YesNo
YesNo
Are you allergic to any medications? (please list all)*
Are you currently using any medications or medical devices?*
Other safety and health concerns
I, the undersigned, give permission for medical treatment in the event that I am incapable of making medical decisions.
Name*

First NameLast Name
Signature*

Clear
Date*

MonthDayYear
Date

Waiver and Liability Release Form
I, the undersigned, being of lawful age for the sole consideration of being allowed and permitted to be a member of the ZOE International organization, hereby and for my heirs, executors, administrators, successors and assigns, waive all rights, demands and claims whatsoever and release, acquit and forever discharge ZOE International and its agents, employees, associated organizations, servants and successors of all claims, actions, causes of action, demands, rights, damages, costs, loss of service, expenses, and compensation whatsoever, which may hereafter accrue out of all ZOE International missions activities.

I recognize that the conditions in some places to which I will travel are not the same standard as the condition to which I am accustomed (i.e., political environments and judicial systems). I realize further that there are certain health and detainment risks as well as other risks to me and my property, and I enter into participation in this trip with knowledge of those risks.

I understand that this document constitutes a full and complete waiver of all possible claims, including claims for negligence in personal injury of property damage, arising out of my participation with ZOE International.

I further understand and agree that all rights under Section 1542 of the Civil Code of any state of territory of the United States and any other nation or country are hereby expressly waived. Said Section reads as follows:

“1542. Certain claims not affected by general release. A general release does not extend to claims which the creditor does not know or suspect to exist in his favor at the time of executing the release, which if known by him must have materially affected his settlement with debtor.”

I further declare and represent that no promise, inducement or agreement not herein expressed has been made to the undersigned, and that this Waiver and Release is contractual and not a mere recital.

THE UNDERSIGNED HAS READ THE FOREGOING WAIVER AND RELEASE AND FULLY UNDERSTANDS IT.
Name of Short-Term Missionary*

First NameLast Name
Signature of Short-Term Missionary*

Clear
Date*

MonthDayYear
Date

Minor’s Travel Permission & Medical Authorization Form

Authorization for Foreign Travel with a Minor
TO WHOM IT MAY CONCERN: This is a letter in relation to my child, a minor of less than 18 years of age. I do solemnly swear that I have legal custody of my child and do hereby grant full authorization and consent for my child to travel outside of Japan with
Parent or Guardian Name
My Child's Full Name

First Name Middle NameLast Name
My Child's Date of Birth

MonthDayYear
My Child is a Citizen of
My Child holds a Passport from this Nation
My Child's Passport Number is
The purpose of travel is a short term mission trip with ZOE. I have approved the following travel plan:
Departure Date From Japan

MonthDayYear
Arrival Date from Thailand to Japan

MonthDayYear
Destination
In addition, I authorize the following person or ZOE to make medical decisions regarding my child in the event of emergency medical treatment as a result of accident or illness or in the event that I cannot be reached.

First NameLast Name
I, the undersigned, agree that the above information is true and I agree to be financially responsible for any medical bills incurred as a result of emergency medical treatment.
Name *Must be a parent or legal guardian of the child

First NameLast Name
Signature

Clear
Date

MonthDayYear
Date
Please input at least one parent/legal guardian information:
Parent # 1

First NameLast Name
Postal Code
Address
Home Phone
Cell Phone
Work Phone
Email
example@example.com
Additional Contact Information
Parent # 2

First NameLast Name
Postal Code
Address
Home Phone
Work Phone
Cell Phone
Email
example@example.com
Additional Contact Information
Should be Empty:

THAILAND STM APPLICATION FORM

Church Information

Reference Policy

Personal Profile

ZOE International's Statement of Faith

Applicant's Statement

Medical Info. & Emergency Release Form

Waiver and Liability Release Form

Minor’s Travel Permission & Medical Authorization Form