Habesha Momma Team Application

Date Submitted

MonthDayYear

Which Trip Dates are you interested in?

ie: April, July, October 2018

Name as it appears on Passport*

First NameMiddle NameLast Name

E-mail*

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number

Area CodePhone Number

Date of Birth*

MonthDayYear

Passport Number

Passport Expiration Date

MonthDayYear

If you do not have a passport have you applied for one?*

YesNo

In case of Emergency please notify*

Name and Phone Numer

T-Shirt Size

Please describe your health, including any physical or dietary limitations*

List any allergies (food, medicine, environment, insects, etc)*

How would you describe your present health?*

ExcellentGoodPoor

Travel Insurance will be required. You may purchase through your own vendor, but proof of purchase will be required before airline tickets are purshased.

What talents or skills do you have that can be used on this trip?

Why do you want to go on this trip?

Upon your acceptance on a team, your deposit becomes non-refundable and will be applied to your total trip cost*

Initials

I will meet the funding schedule supplied in information packet.*

Initials

By submitting this application to be a part of the HM short-term team, you acknowledge that you are personally responsible to pay for, or arrange funding for your portion of the trip costs.*

Initials

I will obtain all documentation and medical services needed for the trip. Passport and vaccination costs are not included in the trip cost and are the responsibility of the team member.*

Initials

I understand that airfare will be secured for me from Washington Dulles airport and that I am responsible for the airfare needed to fly to Washington if applicable.*

Initials

I will submit to the team leader’s and host’s authority. While in country you will be representing Habesha Momma and our partners, so you will be expected to act in a trustworthy, respectful manner to your team leaders as well as the people whom you will be serving.*

Initials

I will refrain from criticizing the local culture's food, language, people, etc....*

Initials

I am willing to work with a positive attitude as a member of a team.*

Initials

I understand that donations received by Habesha Momma are not able to be refunded. If funds are raised over and above my trip cost they will be considered donations to Habesha Momma projects. *

Initials

Please note that if you have to cancel your spot on a trip, you will lose your deposit as well as any money that has been donated on your behalf. Due to accounting restrictions we are unable to refund individuals that cancel after the last payment is made, (unless the trip has been canceled by HM).Those monies will be used towards HM projects and costs.*

Initials

RELEASE, HOLD HARMLESS AND INDEMNITY I, the undersigned, acknowledge that participating in the Habesha Momma, Inc., Ethiopia Trip, (the “Trip”) involves certain risks and that injury, death or other harm (including damage to property) could occur to me (“Injuries”). By participating in the Trip, I hereby assume full responsibility for the risk of Injuries, whether caused by negligence or otherwise. I, on my own behalf and on behalf of my heirs, successors, assigns, executors and administrators, hereby RELEASE AND HOLD HARMLESS AND AGREE TO INDEMNIFY Habesha Momma. Inc, and its staff, volunteer leaders, members, employees, (hereinafter collectively referred to as “Habesha Momma, Inc.”) from and against any and all liability, claims, damages, causes of action, loss, costs and expenses (including, without limitation, attorney fees) for Injuries arising out of or connected with the Trip, including traveling to and from the location(s) of the Trip.*

Full Name

I understand that failure to meet the requirements stated will jeopardize my place on the team and may cause the entire mission trip to be cancelled.*

Initials

Habesha Momma Trip Application

If selected to go on this trip I will agree to the following: