Register

Required fields are marked with an asterisk (*)
 
Full Name *
 
Date of Birth *
 
Address *
 
Phone *
() -
 
Email *
 
Employer *
 
Employer Address
 
Job Title
 
Work Phone
() -
 
Marital Status *
 
Spouse's Name
 
High School Education *
 
College Education
 
Language(s) Spoken
 
Citizenship *
 
Passport Number *
 
Passport Expiration *
 
Emergency Contact *
 
Emergency Contact Name *
 
Relationship to Emergency Contact *
 
Emergency Contact Phone *
() -
 
Emergency Contact Work Phone *
() -
 
Medical Restrictions? *
Yes No
 
If yes, please explain *
 
Are you presently taking any medication? *
  Yes No
 
if yes, please explain *
 
Health Insurance Company *
 
Insurance Policy Number *
I hereby release and hold harmless Worldwide Community Schools and its officers, agents, employees, group leaders, and field representatives from any and all liability for difficulties, damages, injuries or other losses I may sustain, whether or not due to their negligence or any other cause, during the course of the mission trip I am applying for. I understand there are medical risks and risks to my personal safety involved in all aspects of this work trip including, but not limited to, the air and ground travel, lodging accommodations, work activities and recreational activities. I also understand that I may be photographed or videotaped during this trip, and I give Worldwide Community Schools permission to use these images in any way the organization sees fit, for the purpose of raising funds for this school/project and/or for more general marketing purposes.
 
I accept these terms *