Trip Application

Mission Trip Registration Form
Country Traveling To :*
Trip Date From:*

MonthDayYear
Trip Date To:*

MonthDayYear
Full Name (EXACTLY as it appears on your passport)*

First NameMiddle NameLast Name
Sex*

MaleFemale
Date of Birth*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Marital Status*
Phone Number*
E-mail*
Have you gone on a trip with Responders On A Mission Int'l before? When? If not, how did you hear about us?*

Passport Information
Please upload a copy of your passport. Name, Passport Number and Picture must be visible.*

Cancelof
Passport Number*
Passport Date of Issue*

MonthDayYear
Date
Passport Date of Expiration*

MonthDayYear
Date
Country of Issue*

Emergency Contact

Please enter information for an emergency contact below
Emergency Contact*

First NameLast Name
Phone Number*
E-mail*
Relationship*

Medical History/Medical Insurance

Included in your trip cost is a traveler's medical policy - this is in the event of an injury that requires evacuation back to the United States.
Allergies*
Medications*
Medical Conditions*
Medical Insurance Company*
Policy #*
Group #*
Policy Holders Name*
Relationship to Policy Holder*

Personel Information
Please give us a brief description of yourself and why you want to go on this trip*
Do you have any questions regarding the trip?*
If yes, someone from our team will reach out to you.

Participant Liability Release

Given the risk in travel, especially to third world countries and due to unstable world conditions, I am willing to accept full responsibility for all risk and hereby release, waive, discharge, covenant not to sue, agree to indemnify & hold harmless, the Trip/Responders On A Mission International Inc. & its officers, directors, Board of Directors, agents, affiliates, employees, contractors, Legal Counsel, Releasees & associates from any & all damages, liability, causes of action, or any other form of liability, past, present, or future, & whether caused by the negligence of Releasees or otherwise, arising out of or relating to my presence or participation in the Trip/Projects/Training & and any activities related thereto, including but not limited to, Physical and/or Emotional injury or illness, Criminal Victimization, Terroism, imprisonment & Legal Proceedings or any actions taken by Releasees. This Release shall be binding on myself, my heirs, executors, & legal represenatatives. By signing below, I am agreeing that all information above is accurate, allow Responders On A Mission Int'l Inc. to make any decisions regarding medical emergencies on my behalf if I am unable to; and I accept all policies, covenants, & statements listed in this application and Policy & Procedure Manual/Trip Handbook.
Participant Liability Release - Please Sign Here*

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Photography & Media Release

Please be aware that by signing this legal document, you consent to your voice, name, photo, and/or likeness being used, without compensation, in films and tapes for promotion in any and all media, whether now known or devised, for eternity, you release Responders On A Mission Int'l Inc. & its officers, directors, Board of Directors, agents, affiliates, employees, contractors, Legal Counsel, Releasees & associates from any liability whatsoever of any nature.
Photography & Media Release - Please Sign Here*

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Shirt Size for Team Polo*
Please Select
Delta Skymiles Number (if applicable)
Enter the message as it's shown*
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Mission Trip Registration Form

Passport Information

Emergency Contact

Medical History/Medical Insurance

Personel Information

Participant Liability Release

Photography & Media Release