EmailMe Form - Restoring Hope Short Term Missions Application

Name *

First Last

Physical Address *

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

Phone *

### - ### - ####

Email *

Social Security Number
(for background check) *

Date of Birth *

MM / DD / YYYY

Marital status *

Passport info

Do you have a passport? *

Yes

No

Name on passport *

First Last

Passport Number *

Date of issue *

MM / DD / YYYY

Expiration date *

MM / DD / YYYY

Emergency Contact information

Emergency Contact Person *

Relationship? *

Address *

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

Phone number *

### - ### - ####

Email

Trip Information

Have you served with RHI before? *

Yes

No

Planned departure date *

MM / DD / YYYY

Travel Companions or Team Name

Anticipated Cost

Please estimate cost for each line item.
(if you don't have any idea, leave blank)

Plane Tickets

$ Dollars . Cents

Lodging

$ Dollars . Cents

Food

$ Dollars . Cents

Misc

$ Dollars . Cents

Total

$ Dollars . Cents

Insurance

Insurance company with which you have insurance to cover you while in South Africa *

Policy Number *

Health Information

Please list allergies

Please list any history of
serious illness or surgeries

Please list any prescription
drugs you are taking

Background information

Have you ever been accused of physical or sexual abuse? *

Yes

No

If yes, please explain

Is there anything in your personal history that would call into question your ability to work with children? *

Yes

No

If yes, please explain

Have you been involved with alcohol, illegal drugs or been in court within the last year? *

Yes

No

If yes, please explain

Help us make your trip better

What do you hope to participate in?
(check all that apply)

Construction

Outreach

Working with children at the Village

What do you hope to get from this trip?

Please enter your Church's information

Church Name
Pastor's name
Phone number
Address

if you do not attend church
leave blank

TEAM MEMBER AGREEMENT
Assumption of Risk and Waiver:
I understand and accept the risks of my visit to South Africa and The Village. I accept responsibility for myself and my possessions.
Release and Hold Harmless: I agree to release and hold Restoring Hope International, Restoring Hope Trust, The Village, and all staff, officers harmless for any illness, injury, death, personal and/or property damage, property theft, or other loss incurred.

Code of Conduct: I have read and understand The Village Code of Conduct. I agree to abide by it. In addition, I agree to follow instructions given by RHI field staff. I understand that violation of this, or any behavior deemed unsuitable by the Operations Manager could lead to termination of my visit at The Village.
Policies & Procedures: I agree with the policies and procedures of RHI, RHT, and The Village. I am in agreement with the goals of this ministry and my words and conduct will support the spirit of the work.
Certification: I have read this entire Agreement. I understand it and agree to abide by it.

Do you Agree with the above agreement *

Yes

No

Please enter your full name as a signature.
(First, Middle, Last) *