Vision Trip Registration and Release Form
Please fill in the form below.
Congratulations on your decision to join us for this up coming vision trip!
There are just a few things we need to take care of before we can get your giving page set up on our website and your ministry account set up. Please take a few minutes and fill out the form below. Please reach out to your Vision Trip leader with any questions. Also, do not purchase tickets for this trip. The tickets will be purchased for you by the CMM using the funds you raise.
Full Name - Please enter your legal passport name. This is necessary for us when we purchase your plane ticket.
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Prefix
First Name
Middle Name
Last Name
Name you go by - this will be what shows on your giving page.
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Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Phone Number
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Area Code
Phone Number
E-mail
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What University do / did you attend?
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Year of Graduation
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Trip Country
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Trip Start Date
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Month
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Day
Year
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. ]
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Yes
No
Passport Expiration Date
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Please attach photo copy of bio page of passport.
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Browse Files
Cancel
of
How did you hear about this vision trip?
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Please list your experience(s) overseas. Where have you been and for what purpose?
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Why do you want to go on this vision trip? What do you hope to gain from the trip? Please be elaborative.
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Have you ever raised support before?
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Yes
No
Are you willing to raise the support needed to fund the trip?
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Would you like to receive training on how to raise support?
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Yes
No
Medical Information
Please describe any significant health concerns or allergies (diabetes, depression, anxiety, asthma, high blood pressure, food allergies, etc.):
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Are you taking any prescription medicine?
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Yes
No
If so, which ones?
Is the Trip Sponsor authorized to approve medical treatment?
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Yes
No
Name of Emergency Contact
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First Name
Last Name
Phone Number of Emergency Contact
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Area Code
Phone Number
E-mail of Emergency Contact
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example@example.com
Is participant covered by personal/family medical insurance
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Yes
No
If Yes Name of Insurance:
Policy or Group Number:
Liability Waiver
I acknowledge that participation in the Center for Mission Mobilization’s short-term vision Trip (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 the Center for Mission Mobilization or its agents, employees, volunteers, or any other representatives (collectively referred to hereinafter as the “CMM”). Further, the Participant releases and promises to indemnify, defend, and hold harmless the CMM 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 the CMM or otherwise.If a dispute over this agreement or any claim for damages arises, the Participant agrees to resolve the matter through a mutually acceptable Biblically based alternative dispute resolution process. If the Participant and the CMM cannot agree upon such a process, the dispute will be submitted to a three-member arbitration panel for resolution pursuant to the rules of the American Arbitration Association.
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 CMM 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 CMM. 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 CMM 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 the CMM 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
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Today's Date
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Month
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Day
Year
Date
Electronic Signature
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Clear
Submit
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