Name
*
As it appears on your driver's license
First Name
Last Name
Email
*
Gender
*
Male
Female
Date of Birth
*
MM
DD
YYYY
Age
*
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Name 1
*
First Name
Last Name
Relationship to Applicant
*
Phone 1
*
(###)
###
####
Name 2
*
First Name
Last Name
Relationship to Applicant
*
Phone 2
*
(###)
###
####
Name 3
*
First Name
Last Name
Relationship to Applicant
*
Phone 3
*
(###)
###
####
Passport Number (#)
Passport Date Issued
MM
DD
YYYY
Passport Expiration Date
MM
DD
YYYY
Issued City/State
Nationality
Date of Birth
MM
DD
YYYY
Treatments
Has the participant ever been treated by a doctor for any of the following? Check all that apply.
Diseases
Has the applicant ever been treated by a doctor for any of the following diseases? Check all that apply.
Allergies
Does the applicant struggle with any of the following allergies? Check all that apply.
Please list any Operations or Serious Injuries
Please list any Disabilities or Serious Illnesses
Please list any Dietary or Activity Restrictions
Please list your Current Medications including any helpful instructions
Please list any other comments/information about your medical needs
Date of last Tetanus Shot
*
MM
DD
YYYY
Height (feet/inches)
*
Weight (lbs)
*
Physician Name
*
Physician Phone
*
(###)
###
####
Physician Address
*
Insurance Carrier Name
Group/Policy #
Name of Policy Holder
First Name
Last Name
International Health Coverage
NOTE: JPM requires each mission participant to carry “International Health Coverage” Insurance. With your permission, a policy will be taken out in your name by JPM. For additional insurance please contact us.
I will make every effort to meet the deadlines for turning in my money and know that I may be removed from the team if this is not fulfilled. (All money turned in is non-refundable.)
*
As a team member, I will work under the leadership of Joey Potter Missions, JPM Staff and my team leaders; following the behavioral, spiritual, and safety guidelines that are given to our team.
*
I will not complain during the trip and/or cause dissension.
*
I understand that I am not to pursue any romantic interest or develop any “special relationship” during this trip (be physical with this person in any way). Should I become interested in anyone during the trip, I understand that I may tell a team leader about this interest if I so choose, but that I may not discuss it with this person or with any other participant during the trip.
*
I will follow the team’s and the culture’s dress codes.
*
I will be sensitive to the practices, food, and living situations of the culture that I am visiting and I will not criticize or complain.
*
I understand that I may be sent back to the U.S. at my own expense if I’m unable or unwilling to meet the above conditions.
*
I commit to completing the required training videos, reading material and Enneagram test to come after submitting this application.
*
Participant Electronic Signature
*
The electronic entering of your first and last name below acts as your electronic signature.
First Name
Last Name
Today's Date
*
MM
DD
YYYY
Parent/Guardian Electronic Signaure
(If applicable)
First Name
Last Name
Today's Date
MM
DD
YYYY
I do understand the risks involved in participating in a trip with JPM Missions Projects. I assume full responsibility for myself, or my child if a minor, for any and all risks.
*
I understand Joey Potter Missions reserves the right to refuse any person it judges to be incapable of meeting the rigors and requirements of participating in its activities. I therefore certify that the medical and health information I have provided on this form is true and accurate to the best of my knowledge. I, or my child if a minor, am/is in good physical condition and therefore fully capable of participating in and able to undertake all of the activities involved in a JPM experience. I, or my child if a minor, do/does not have any medical condition that would prevent my, or his/her, participation except for those restrictions listed in Section D of this form.
*
I, or my child if a minor, agree not to use alcohol or illegal drugs while participating in JPM. I also assume full financial responsibility for any physical damage to persons or property caused by myself, or my child if a minor.
*
I hereby authorize and release to JPM the use of my image, or my child’s if a minor, in a video recording or photograph for any purpose of Joey Potter Missions Projects.
*
I hereby give permission for any qualified medical personnel to render necessary emergency medical care for myself, or for my child if a minor. I also give said personnel the permission to make any necessary judgment decisions. I certify that I have adequate health, disability, and life insurance for myself, or for my child if a minor.
*
I agree that, should there be an issue or dispute as to the validity of any release that I have signed, this document shall supersede any other document that I have read and signed about my legal rights concerning Joey Potter Missions. I also understand that the terms of this agreement shall continue to be in effect even after the trip has ended.
*
Therefore I,
*
First Name
Last Name
of my own free will, for my family, my children who are minors, my heirs and executors, and myself, have read, understand, and acknowledge the risks and liability for myself and my family on this day.
*
MM
DD
YYYY
Participant Electronic Signature
*
First Name
Last Name
Parent/Guardian Electronic Signature
If participant is a minor.
First Name
Last Name
