Trip application

General Information

Which team are you applying for?(Required)

Name (as it appears on your passport)(Required)

First Middle Last

Nickname (if applicable)

Date of Birth(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Email(Required)

Gender(Required)

Occupation(Required)

Employer(Required)

List your personal strengths and skills useful for this project/trip:(Required)

List your weaknesses:(Required)

List some personal goals you would like to accomplish by participating in this project/trip:(Required)

List church affiliation (if any) and describe your involvement:

Have you ever been arrested or charged with any criminal offense in any country?(Required)

Yes

No

You will receive an e-mail from Clear Investigative Advantage Research (CIAResearch) requesting permission for a mandatory background check.

If yes, please explain:(Required)

Emergency Contact and Medical Information

As standard procedure, we require the following information from everyone participating on a trip with Healing Nations. This information will be kept confidential.

Do you have any medical conditions that you are currently being treated for? Do you take any prescription medications for any reason?(Required)

Yes

No

Please list any conditions you are being treated for along with medications you currently take:(Required)

(Be sure to bring all allergy and/or prescription medications in their original containers)

Do you have any allergies?(Required)

Yes

No

Please list allergies and allergy medications you take:(Required)

Emergency Contact #1(Required)

First Name Last Name

Relationship(Required)

Phone(Required)

Emergency Contact #2(Required)

First Name Last Name

Relationship(Required)

Phone(Required)

References

Please list two references and let them know they will be receiving an e-mail from Healing Nations with a link to our reference forms. Your application is not considered complete until your references have completed their forms.

Friend/Peer Reference(Required)

First Name Last Name

Friend/Peer Email(Required)

Enter Email Confirm Email

Spiritual Leader or Recent Employer Reference(Required)

First Name Last Name

Spiritual Leader or Recent Employer Email(Required)

Enter Email Confirm Email

Passport

Please upload a color copy of pages 2/3 of your passport. If you have not yet received your passport, please upload a copy of your passport application. If you haven't yet applied for a passport, send your passport application to [email protected] as soon as you've submitted it.

Drop files here or

Accepted file types: jpg, png, pdf, jpeg, Max. file size: 250 MB, Max. files: 3.

Project Waiver, Crisis Policy, and Code of Conduct

Please read the document below in its entirety before signing and submitting your application. This form will be printable from the confirmation screen and confirmation e-mail. Please print a copy for your records.(Required)

I agree to the Waiver, Crisis Policy, and Code of Conduct

Deposit Information

Upon signing this form, you agree to pay an initial deposit of $300 per applicant that is non-refundable. This deposit will be collected by your church or group leader.

Signature(Required)

Must be signed by a parent or legal guardian if under the age of 18. By signing above, I declare that all information disclosed in this document is correct to the best of my knowledge. I have read and agree to the Project Waiver/Liability Release, Code of Conduct, and Crisis Policy and am in compliance with all documents and statements therein.