Clone of Team Member Information and Release Form

1

What is the best email address to reach you regarding your upcoming trip?

example@example.com

2

What is your current mailing address?

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

3

When is your birthdate?

Date

5

Do you have a valid U.S. Passport?

YESNO

6

When does your U.S. Passport expire?The Republic of Kenya requires your passport be valid for at least six (6) months after your departure date.

Date

7

Does your current passport have at least two (2) blank pages?The Republic of Kenya requires at least two blank endorsement pages in your valid passport.

YESNO

8

What is your name (as it appears on your passport)?

First Name

Middle Name

Last Name

Suffix

9

What is your passport number?

10

Please upload a photo of your passport's identification page.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

11

What was your country of birth?

United States of America

Other

12

What was your nationality at birth?

United States of America

Other

13

Have you ever been convicted of any offence, under any system of law, in the past 5 years?

YESNO

14

Details of conviction:

15

Have you ever been previously denied entry to Kenya?

YESNO

17

Have you previously visited Kenya more than three times?

YESNO

18

Take or Upload a Clear Photo of YourselfThis photo will be used for your Kenya eTA (visa) application.

19

Emergency Contact NameWho should we contact in the case of emergency?

First Name

Last Name

20

Emergency Contact Phone Number

Area Code

Phone Number

21

Delta SkyMiles: If you have a Delta SkyMiles number, please enter it below.If your trip travels on a Delta or SkyTeam flight, we'll include your SkyMiles number when purchasing tickets to help you earn miles.

22

United MileagePlus: If you have a MileagePlus number, please enter it below.If your trip travels on a United or Star Alliance flight, we'll include your MileagePlus number when purchasing tickets to help you earn miles.

23

American AAdvantage: If you have an AAdvantage number, please enter it below.If your trip travels on an American or oneworld flight, we'll include your AAdvantage number when purchasing tickets to help you earn miles.

24

Do you have a Known Traveler Number (like TSA PreCheck or Global Entry)?A Known Traveler Number is provided if you have TSA PreCheck or are part of Trusted Traveler Programs like Global Entry.

YESNO

25

What is your Known Traveler Number?This is the number provided with your TSA PreCheck membership, or your Global Entry

26

Even if you have expedited options for security checkpoints (like TSA PreCheck) or passport control (like Global Entry), your team leader may ask you to join the regular queue lines to keep the group together. Please follow your team leader's directions.

I understand.

27

Kenya Hope will acquire traveler’s insurance for the days of your trip. Do you have any medical conditions or concerns that we should be aware of?

YESNO

28

Please list or describe your medical conditions/concerns.

29

Infectious DiseaseKenya Hope highly recommends you visit your Primary Care Physician and/or an International Travel or Infectious Disease Doctor at least one month before your planned travel to consider required, encouraged, and recommended vaccinations and medicines for international travel. These medications are to protect you and your fellow teammates from foreign diseases, as well as protect Kenyans from diseases you may bring into the country. You likely will be visiting Nairobi and the surrounding areas, including Kibera, and areas to the south and west of Nairobi, primarily in Narok County.

I understand.

30

Using the email address and contact information provided previously, Kenya Hope will inform the U.S. Embassy Nairobi of your travel, and inform the U.S. Department of State of your intention to travel to Kenya. You may receive email updates from the Embassy and/or State Department.* This field is required.

I understand.

31

Kenya Hope will complete your eTA (visa) application.* This field is required.To enter Kenya, you are required to have a valid visa (called an electronic travel authorisation, or eTA). To simplify the process, Kenya Hope will apply for the eTA on your behalf. Once completed and accepted, you will receive a copy of your eTA and supporting paperwork.

I understand.

32

Participant and Media Release Agreements* This field is required.

33

I affirm the above information is accurate and complete to the best of my knowledge and capabilities.