Form

Trip Start Date Trip End Date

First Middle

Last Social Security Number

Date Of Birth Preferred Name (name you wish to be called)

Address City

State Zip code

Home Phone Cell

Email Passport Number

Expiration Date T-Shirt Size

Team Leader Name Name of church you attend

Pastor's Name

First Name   Last Name   Relationship Contact Number    Email   

Insurance Company Policy Holder

Relationship Policy Number

Group Insurance Co. Address

Phone Number

TO BE COMPLETED BY APPLICANT IF 18 OR OLDER OR BY A PARENT OR GUARDIAN OF APPLICANT IF APPLICANT IS UNDER THE AGE OF 18.
In consideration of my being accepted by SoloHope, INC for participation on a Mission Team to Honduras on thru , I make the representations and undertakings set out below: 
I am in good health and have received or will receive all vaccinations recommended by my county or state health department for travel in the countries or areas to be visited on this trip. 

I know that international travel involves danger and risk. I acknowledge that the dangers and risks include, but are not limited to, the hazards of travel by air, boat, raft, jeep, automobile, bus, taxi, bicycle, and on foot, travel in foreign countries, in jungles, mountains, high altitudes, steep terrain; travel and/or attendance at meetings among possibly unfriendly persons; sickness or injury in areas where medical assistance may be primitive or inadequate, unavailable or not readily available, and/or where rapid evacuation is not available; or where there is exposure to crime, to civil unrest and to forces of nature or other dangers. I understand that the above and other possibilities are risks in ministry/missions travel. 
In the event of an emergency, I hereby authorize the team leader of this trip, appointed by SoloHope or their appointed leader, as an agent for me to consent to: any x-ray examination; to hospitalize, anesthetize, or perform surgery as needed; consent to medical, dental, or surgical diagnosis; treatments; hospital care advised and supervised by a physician, surgeon, or dentist (as appropriate) licensed to practice under the law of the state or country where services are rendered, either at a doctor’s office or in a hospital. I expect that my family will be contacted by telephone or email as soon as possible after any illness or injury. 
I acknowledge that SoloHope has recommended that I carry or obtain primary medical insurance to cover possible medical needs including evacuation occurring during this trip and that SoloHope has required that I obtain travel insurance covering personal injury, trip delay, change or cancellation, loss of or damage to baggage, and other standard risk coverage for this trip. I understand that if travel insurance is NOT obtained, I may be forfeiting my place on this trip and any fees that may have been paid. 

I hereby assume all risk of personal injury, sickness, or death, and damage to or loss of my personal property, and any delay, change or cancellation of travel arrangements, and all other damage or expenses I may suffer because of participation in the trip or in activities related to it. I agree to be fully responsible for my actions. Should I become ill or injured or suffer other damage, I will pay all costs involved including costs of my evacuation and medical care I might receive.

 

In consideration of my being permitted to participate as a SoloHope member on the above missions trip, I accept and assume all risks and hazards from this activity, both known and unknown, including but not limited to the risks and hazards identified above.

I hereby voluntarily release, forever discharge, and agree to hold harmless and indemnify SoloHope, its directors , officers, agents, employees, coordinators, facilitators, volunteer, and other team members from any and all liability, claims, demands, actions or rights or actions, which are related to, arise out of, or are in any way connected with my participation in this activity, which I now have or may have in the future, specifically including but not limited to the negligent acts or omissions of any person so released, held harmless and indemnified , and specifically including claims relating to any personal injury that I may suffer.

I agree not to make a claim, file suit or demand anything for any injury, death or loss that arises from my participation in this activity.

I agree to pay the costs and/or legal expenses incurred by the trip leader(s) organizers and/or participants as a result of any claim or suit filed by me, or filed by anyone else as a result of my conduct.
I consent and agree to pay for any medical treatment rendered to me by anyone for any injury or other medical situation during, or resulting from, my participation.

I authorize SoloHope to arrange for transportation, food, and lodging for me on this trip.

I agree that these promises, agreements, assumptions of risk and releases bind me, my family, all minors with me or on whose behalf I sign, and my heirs or legal representatives and assigns.