Via Release Form - Short-term

RELEASE FORM

for Via Short-term Projects
There are just a few things we need to take care so we can get your ministry account and giving page set up.

1. Please take a few minutes and fill out the form below.
2. Do not purchase tickets for this trip. The tickets will be purchased for you by the Via using the funds you raise.
3. Please reach out to your Via staff contact with any questions.
GENERAL INFORMATION
Full Name - Please enter your legal name as it appears on your passport. This is necessary for us when we purchase your plane ticket.*

PrefixFirst NameMiddle NameLast Name
Name you go by - this will be what shows on your giving page.*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
E-mail*
What University do / did you attend?*
Year of Graduation*
Trip Country*
write "USA" if a domestic internship or trip
Start Date*

MonthDayYear
Date
Which vision trip are you going on?
PASSPORT
Do you have an updated passport? (Passport's expiration date must be at least 6 months from date of trip. ]

YesNo
Passport Expiration Date*
Passport Number*
Please attach photo copy of bio page of passport.*

Browse Files

Cancelof
How did you hear about this vision trip?*
Please list your experience(s) overseas. Where have you been and for what purpose?*
Why do you want to go on this vision trip? What do you hope to gain from the trip? Please be elaborative.*
Have you ever raised support before?*

YesNo
Are you willing to raise the support needed to fund the trip?*
Would you like to receive training on how to raise support?*

YesNo
MEDICAL INFORMATION
Please describe any significant health concerns or allergies (diabetes, depression, anxiety, asthma, high blood pressure, food allergies, etc.):*
Are you taking any prescription medicine?*

YesNo
If so, which ones? Do you need any special accommodations for this medication?
Name of Emergency Contact in the United States:*

First NameLast Name
Phone Number of Emergency Contact*

Area CodePhone Number
E-mail of Emergency Contact*
example@example.com
Are you covered by personal/family medical insurance*

YesNo
If Yes Name of Insurance:
Policy or Group Number:
AGREEMENTS
Liability Waiver

I acknowledge that participation in Via’s short-term vision trip, Summer Project, or Internship (referred to as “Trip” throughout this document) involves risk to myself as the Participant (referred to as “Participant” throughout this document), and may result in various types of injury including, but not limited to, the following: sickness, bodily injury, death, emotional injury, personal injury, property damage and financial damage. In consideration for the opportunity to participate in the above Trip, the Participant acknowledges and accepts the risks of injury associated with participation in the Trip. The Participant accepts personal financial responsibility for any injury or other loss sustained during the Trip or during transportation to and from the Trip, as well as for any medical treatment rendered to the Participant that is authorized by Via or its agents, employees, volunteers, or any other representatives (collectively referred to hereinafter as "Via”). Further, the Participant releases and promises to indemnify, defend, and hold harmless Via and its agents, employees, volunteers, or any other representatives for any injury related directly or indirectly out of the above Trip, whether such injury arises out of the negligence of Via or otherwise. If a dispute over this agreement or any claim for damages arises, the Participant agrees to resolve the matter through a Bible-based alternative dispute resolution process.
Medical Authorization

If, while participating in the Trip, I require emergency medical treatment, I hereby give my consent for any emergency medical care to be rendered as may be deemed necessary by any duly licensed physician or dentist. I hereby give my permission to Via to obtain the emergency medical treatment at any hospital, clinic or other health care provider as may be deemed appropriate. In these circumstances, I hereby request and authorize any duly licensed physicians, dentists and staff, or other licensed technicians or nurses, to perform any diagnostic procedures, treatment procedures, operative procedures and x-ray treatment as may be necessary, including but not limited to medical transport, hospital tests, injections, anesthesia, surgery and administration of prescription drugs. I agree to the release of any records necessary for treatment, referral, billing or insurance purposes from any Medical Contacts provided by Via. I agree to assume and pay for all costs of such emergency medical treatment.
Photo and Video Use Agreement

My permission is granted for the Via to videotape or photograph me during ministry events or normal activities. I understand these photos may be used as promotional or training materials.
Signature

By digitally signing below, I acknowledge and warrant that the information that I have provided on this form is true and correct to the best of my knowledge. I further agree to immediately notify Via of any change in the information presented. I understand that this form is valid and legally binding until revoked in writing by the Participant.
Full Name*
Today's Date*

MonthDayYear
Date
Electronic Signature*

Clear
Should be Empty:

RELEASE FORM

GENERAL INFORMATION

PASSPORT

MEDICAL INFORMATION

AGREEMENTS

Liability Waiver

Medical Authorization

Photo and Video Use Agreement

Signature