Service Trip Application Step 1 of 4 25% Name As It Appears On Passport* First Middle Last Date of Birth Date Format: MM slash DD slash YYYY GenderFemaleMaleCell Phone*Email* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Passport Number*Expiration Date* Date Format: MM slash DD slash YYYY Parent or Guardian Information (for traveler's under 18)Parent or Guardian's Name First Last Parent or Guardian's Phone NumberParent or Guardian's Email Emergency Contact InformationName First Last RelationshipPhoneEmail About YouPlease list any skills or talents you have and may be willing to share during your trip. (ex. medical, teaching, music, construction)Please list any previous service/mission trips you have experienced:Have you ever traveled outside of the U.S.? Haiti Trip Participation Agreement Traveling in developing nations, like Haiti, is much riskier than traveling within the U.S. Grace and Glory has taken all reasonable and prudent measures to reduce foreseeable risks, but we can’t elimnate all risk of personal injury, property damage, and death. These risks in Haiti are increased by factors such as geographic and climate conditions, forces of nature, hygienic standards, disease, biomedical hazards, infrastructure problems, crime and civil unrest. In addition, medical services or facilities may not be readily available during portions of our trip and, if available, may not be equal to standards in the U.S. While in Haiti, we are subject to Haitian law. Should you develop any legal problems with the Haitian government, you shall be solely responsible for resolving those issues. In exchange for being allowed to participate in the trip, you, your heirs, and assigns release, discharge and hold harmless Grace and Glory, it’s officers and directors from any claims, demands, damages, actions or causes of action resulting from or related to your participation on this trip, including but not limited to any claim for personal injury or wrongful death. This release is made voluntarily by you with full awareness of the risks associated with the trip. I give Grace and Glory and it's representatives with me on any such trip, authority to request and authorize medical and/or hospital treatment for my benefit in the event of an injury or sickness sustained by me while on such service trip, including without limitation, while traveling to and from the destination. I agree to pay for all such treatment and to reimburse Grace and Glory for all cost and expenses incurred by it with respect to such treatment. By signing this agreement you affirm that you are over the age of eighteen years, or are the parent or guardian of minor traveling, that you have read the information contained in this packet, and that you fully understand the terms and conditions contained in this agreement. By typing your name here it serves as your signature and you are agreeing to the terms above:Name of Traveler (or guardian if under 18)* First Last Today's Date* Date Format: MM slash DD slash YYYY Payment InformationA $200 deposit is required to reserve your spot on the trip. You may pay by credit card or check. Service Trip Date*March 1-8, 2016November 1-8, 2016Service Trip Deposit*Total $0.00 Credit Card American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20212022202320242025202620272028202920302031203220332034203520362037203820392040 Expiration Date Security Code Cardholder Name Billing Address* Street Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Email If you prefer to pay by check please mail your $200 deposit to Grace and Glory at P.O. Box 11914, Murfreesboro TN 37129. Don't forget to hit submit to send us your application information!