Traveler Profile Form

This form must be completed and submitted at least six weeks prior to your departure date.

"*" indicates required fields

Name*

First Middle Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Cell Phone*

Email*

Date of Birth*

Sex*

Male

Female

Local Church

Group(s) of children to visit (if any)

Profession

Trip Location*

Date Trip Begins*

Date Trip Ends*

Passport Number*

Emergency Contact*

First Last

Relationship to you*

Emergency Contact's Phone Number*

Emergency Contact's Email

Physician's Name*

First Last

Physician's Phone Number*

Medical Insurance Provider*

Medical Insurance Policy Number*

Medical Insurance Provider's Phone Number*

Allergies and Medications

Physical disabilities and health related issues (indicate if you require special accommodations regarding sleeping arrangements, meals, etc.)

The following guidelines are recommended by Zoe Empowers Ministry for all participants of a Zoe Empowers Trip of Hope. Therefore, in consideration of the opportunity to participate in the trip, please review the following agreement and electronically sign below:

I agree to share my faith in an appropriate Christian manner.
I agree to cooperate at all times with the team leader concerning our work and life together including daily assignments, food, lodging, transportation, and to stay with the team the duration of the trip.
I agree to abstain from offensive habits while on the mission, including use of alcohol or tobacco products. (The use of alcohol and tobacco is unacceptable for Christians in many countries).
I agree to avoid discussing sensitive topics, including politics (domestic and/or international), sexuality, alcohol, an individual’s HIV/AIDS status, and tribal background (especially in Rwanda.) (It is fine for our Africa staff to speak about these things but it will be at their discretion.)
Further, I hereby release and discharge the mission organizations which assisted in these arrangements, their agents, employees, and officers, from all claims, demands, actions, judgments, and executions which I ever had, or now have, or may have or claim to have, against the mission organizations, their agents, employees, and officers, and their successors or assigns for all personal injuries to personal property, real or personal, caused by, or arising out of, the above described mission service. I intend to be legally bound by this statement.
I hereby acknowledge that by engaging in this mission, I am subjecting myself to certain risks voluntarily, including and in addition to those risks which I normally face in my personal and business life, including but not limited to such things as health hazards due to poor food and water, diseases, pests, and poor sanitation; potential danger from lack of control over local population; potential injury while working; and inadequate medical facilities, etc.
If I am unable to do so, I authorize the “Trip Leader” (named above) to consent to any necessary examination, anesthetic, medical diagnosis, surgery, or treatment and/or hospital care rendered to me under the general or special supervision and on the advice of any physician and surgeon licensed to practice medicine by the state or country in which they practice, during the duration of the trip identified above.

Signature*

I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written signature.

Passport Copy Upload

Max. file size: 100 MB.

Please upload a copy of your passport here. You may submit this form without providing a copy of your passport, but it is required that you send it to elena@WeAreZOE.org prior to your departure.

Traveler Profile Form

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