JPM Application

Statement of Purpose
Joey Potter Missions does everything possible to ensure that all participants enjoy a safe and life-changing experience. As part of our commitment to safety, we want to inform you that your trip and activities are not free from risk. These activities may include using power tools, working off the ground on ladders and roofs, camping, and other activities. We do not want to reduce your enthusiasm for your experience, or to cause you to be overly concerned, but we do want you to be aware of the risks that are involved with your trip. JPM Missions further wishes to inform you that the personal information you provide will be used strictly for administrative and operating purposes. Examples may include, but are not limited to, compilation of trip rosters, record keeping for insurance purposes, and situations of professional or emergency medical treatment. The information you provide will be kept safe to the best of our ability, and we will not release or share your information for other purposes without permission from you.
Participant Information
Name *
As on drivers license
Date Of Birth *
Date Of Birth
Home Address *
Home Address
Phone *
Emergency Contact
You must list three contacts in case of emergency in order of priority to be contacted.
Name 1 *
Name 1
Phone # *
Phone #
Passport Name as is on the Passport
General Health History
Has the participant ever been treated by a doctor for any of the following? Every item must be checked.
Diseases *
Severe Allergies *
Date of Last Tetanus Shot *
Date of Last Tetanus Shot
Phone # *
Phone #
Do you carry family medical or hospital insurance? *
If yes, please list your policy information below.
Name of Policy Holder
Name of Policy Holder
(NOTE: JPM Missions requires each participant to carry “International Health Coverage” Insurance. A policy has been taken out in your name by JPM Missions with your permission. For additional insurance please contact JPM Missions.)
Joey Potter Missions Project Covenant
To be filled out by the JPM Participant. Please click "I Commit" after each statement once you have read it. After you have completed reading the entire covenant, sign at the bottom and if you are under 18, your parent/guardian must sign also.
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 the JPM. 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 as 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. *
Participant Electronic Signature *
Participant Electronic Signature
Date *
Parents/Guardian Electronic Signature
Parents/Guardian Electronic Signature
Travel Release for Participants Under Age 18
I give my permission for my daughter/son to travel with Joey Potter Missions, while on this mission trip.
Parents/Guardian Electronic Signature
Parents/Guardian Electronic Signature
Acceptance of Risk and Release of Liability
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 JPM 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, *
Therefore I,
Your 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.
Date *
Participant Electronic Signature *
Participant Electronic Signature
Parents/Guardians Electronic Signature (If a Minor)
Parents/Guardians Electronic Signature (If a Minor)