Mexico GO Team (February 2018) Application

Full Name (Required) *

First Name
Last Name

Your Email Address (Required) *

**EACH GO TEAM PARTICIPANT MUST HAVE THEIR OWN EMAIL ADDRESS

Your Address

Street address
Street address 2
- City
- State / Province
- zip code
- Country

When entering your phone number, please do not put any dashes (i.e. 3565126)

Mobile Phone

-
Area Code
Phone Number

Home Phone

-
Area Code
Phone Number

Work Phone

-
Area Code
Phone Number

Gender

Male
Female

Marital Status

Date of Birth

Month
Day
Year

Emergency Contact Name

First Name
Last Name

Emergency Contact Phone

-
Area Code
Phone Number

Emergency Contact Relationship

Emergency Contact Email

Passport Number

Passport Expiration

Month
Day
Year

Name on Passport

Will you be taking the roundtrip Calvary bus to San Diego? (The bus is included in the price of the trip). *

Yes
No

If GO Team participant is under 18 years of age, please fill in the information below.

Name of Parent or Guardian

Phone Number of Parent or Guardian

Email of Parent or Guardian

MEDICAL INFORMATION

Calvary Church does not carry accident insurance for group activities. Should an accident or injury occur, you will be expected to cover all the medical expenses involved. The information you provide above will help us in getting immediate medical care should an accident occur. This is confidential information for use in medical emergencies.

Name of Insurance Company *

Policy Number *

Primary Doctor's Name & Phone Number *

I give any licensed, practicing physician or hospital full authority to provide emergency medical treatment for me in the event such treatment is needed or necessary and I am not able to make such a decision. I also hereby give my permission for a licensed practicing physician to administer whatever medical treatment he/she may deem necessary for me in the event of any medical emergency affecting me.

I agree to the above statement *

Yes
No

ABILITIES

Present Occupation *

Name of Employer or School *

If you are a student, list grade

BACKGROUND CHECK

We desire to provide a safe and secure environment for the GO Team members and the youth around the world. We will be completing a background check on all GO Team participants. All information is held strictly confidential by the Calvary Church staff. It is our desire to work with you to find a ministry that is fulfilling and suited to your strengths and experiences.

In addition to our background check, are there any issues in your past that may compromise your ability to participate on this trip?

*

No
Yes

If yes, please explain.

CROSS-CULTURAL/ TRAVEL EXPERIENCE

Have you participated on a GO Team before? *

Yes
No

If yes, which GO Team(s)?

SPIRITUAL PROFILE

Check which one applies *

Actively attending Calvary Church
Not involved at a church
Attending another church

If you attend another church, which church do you attend?

TRIP COVENANT

If selected to be a member of this GO Team, you will be expected to honor each of these commitments.

• I understand that prior to my going on the trip, I am responsible for covering any shortfall in my trip finances. Any amount due is ultimately my responsibility. I understand the total amount is due 30 days prior to the trip departure date.

• I understand that contributions (either my own or others on my behalf) are non-refundable in the event that I do not participate in this trip (whether by my choice or that of the church). Funds will be applied toward the trip project costs.

• I will be supportive of the leader(s) chosen for this trip and will submit to his/her/their overall leadership.

• I will enter this trip with a spirit of flexibility, realizing that a number of our plans will inevitably change while in a cross-cultural setting.

• I will attend all GO Team meetings, realizing participation in these meetings is non-negotiable. I agree to meeting after we return from the GO Team for debrief meetings.

• I understand that Calvary Church has the right to discontinue my involvement in this trip at its sole discretion.

• I will be a team player, placing the needs and objectives of the group above that of my own.

• I agree to allow the leaders the keep me accountable in upholding the agreements I have signed.

• In case of emergency, I hereby give my permission to any licensed physician and hospital selected by the team leader to hospitalize, secure treatment for, and to order injection, anesthesia, or surgery for myself or the below named. I understand that Calvary Church will not be held responsible in the event of accident or injury.

• I understand that I am required to provide a 10% (of the total trip cost), non-refundable deposit, with the submission of this application.

• I understand that the total cost of this trip does not include any immunization costs, medicine, passport costs, visa costs, souvenirs, etc.

• I hereby release an unrestricted right to use photographic images of myself (or the below named minor of whom I am the legal guardian), video or still, including audio, for use in print, DVD, internet distribution and/or other media to promote the work of Calvary Church Los Gatos. Any such images will be used in high ethical and moral standards and will maintain a high level of integrity. I understand that I will not be compensated for the use of these images.

I acknowledge that I have read and agree to all information contained in the Trip Covenant.

*

Yes
No

RELEASE OF LIABILITY

I acknowledge that I am participating on a GO Team through Calvary Baptist Church of Los Gatos (Calvary). I will not hold or attempt to hold Calvary liable for any loss, damage or injury to person or property caused by any act or neglect of other persons on or about this trip, and I will indemnify and hold Calvary harmless from any liability for damages or claims against Calvary arising out of or in any way related to any such loss, damage or injury.

I release Calvary, including its trustees, employees, and agents from my physical injury, including death or illness while on this trip or while in transport to and from there. I will assume the risk associated therewith, whether known or unknown to me at this time. This release is also intended to include all claims of my family, estate, heirs, personal representatives or assigns.

I verify that I am in good health and am capable of participating in strenuous activities, and when necessary, will tailor my activities to those within the bounds of my physical health. I hereby swear that I am 18 years age or older and am legally able to sign this release.

By typing my name in the signature box below, I acknowledge that I have read and agree to all information contained in the Trip Covenant and Release of Liability and that this will serve as my true signature.

Signature of GO Team Participant *

Date *

RELEASE OF LIABILITY FOR MINORS (UNDER 18)

If I am under 18, my parent or guardian, by typing below, also consents to my release & he or she agrees that this release shall be binding upon him or her as my parent or guardian as to me & my estate, heirs, personal representatives & assigns. My parent or guardian also promises, by typing below to defend, indemnify & hold Calvary harmless form any claim asserted by me against Calvary, including its trustees, employees and agents, if I should repudiate this release after obtaining adulthood.

Signature of GO Team Participant or Legal Guardian

Date