Dates of Mission Trip: From _____________
To _____________, 200___
NAME_____________________________________________ DOB:____
Address________________________________________
Passport #_________________
Issue Date:________________
Phone: (H)_________________
(O)__________________
E-Mail
Address_________________________________________
Spouse’s Name (if
applicable)_____________________________
If Volunteer is a minor, this must be
signed by him/her & a parent/guardian.
Bring it with you.
MEDICAL
INFORMATION
Are you allergic to any
medication?
No___ Yes___
If Yes, please specify:
___________________________________________________
Are you presently taking
medications?
No___ Yes___
If Yes, please specify:
___________________________________________________
Do you have any special
dietary needs? No___ Yes___
If Yes, please specify:
____________________________________________________
EMERGENCY CONTACT
Name______________________________________
Phone______________________
Address________________________________________________________________
Relationship to you:
______________________________
ALCOHOL, DRUG & TOBACCO POLICY
I understand that no alcohol, drugs or
tobacco are permitted while on the mission trip with
Songs of Joy, and any
violation of this policy will result in my being sent home immediately.
Volunteer Signature:
_____________________________________ Date: ____________
Parent/Guardian Signature:
________________________________ Date: ____________
CONSENT FOR
TREATMENT
In case of emergency, I hereby agree to
the performance of such treatment, including
anesthesia and surgery, as an attending doctor may deem necessary [for my
son/daughter].
Volunteer Signature:
_____________________________________ Date: ____________
Parent/Guardian Signature:
________________________________ Date: ____________
RELEASE OF
LIABILITY
I do hereby release Songs of Joy Home for
Children, its staff, agents and volunteer
assistants from any liability
whatsoever arising out of any injury, damage or loss which
may be sustained by
myself or my family during the course of involvement with the
mission in
Guatemala, Central America.
Volunteer Signature:
_____________________________________ Date: ____________
Parent/Guardian Signature:
________________________________ Date: ____________
(Updated
12/04)
