El Salvador Mission/Study Trip
Application
El Salvador/Guatemala Trip Dates: July 31- Aug 10
Please print in ink (Or type and e-mail)
Name:
Age:
LAST
Male
Female
FIRST
Birthday:
MIDDLE
Email
Address
City
State
Phone
Pager / cell
Emergency contact
Phone: Home
Zip
Work
Church Name
1. What is the best way to contact you?
2. Do you have health or dietary concerns we as leaders of the trip should be aware of?
3. Why do you want to come on this trip?
4. What talents, skills, knowledge, or gifts do you bring to the group and to the trip?
□ picture taking
□ movie making
□ music. Which instruments?_________________________
□ administration
□ children’s ministry □ medical work, what specialization?___________________
□ computer maintenance/connections for donated computers? ____________________________________
□ connections for medical/health supplies? describe____________________________________________
□ handy/repair skills, construction skills
□ other?_________________________________________
5. What projects particularly interest you? (check all that apply)
□ Building/Construction
□ Dental/Medical Mission
□ Helping Pastoral Team (Matias) □ School/Children’s Ministry
□ Helping in Guest House
□ Hope House Homeless Ministry
6. Do you commit to participating in all scheduled group gatherings and devotions during the mission trip, including
during our August 8-10th stay in Antigua, Guatemala?
□ YES
□ NO
6. Is there anyone else you would like Julie to send more information to? If so, place their information. (complete
name, address, phone, email)___________________________________________________________________
Please mail to us:
• This Application Form for each participant
• Emergency Contact/Medical Info for each participant
• Waiver and Medical Release Form for each participant (there’s a different one for minors, along with a
letter that must be filled out an notarized for children travelling without a parent)
• Photocopy of the first photo page of your passport
• $200 Non-Refundable Deposit Check made out to Julie Jacks (please send by mail)
And send to:
Julie Jacks, 505 Larsson Street, Manhattan Beach, CA 90266
If you have any questions, feel free to call Julie at: 310-798-9081
Thank you! ¡Muchas Gracias!
Emergency Contact Information
El Salvador and Guatemala Trip
My Name:___________________________________________ My birthdate, month, year:_____________
IN CASE OF EMERGENCY, PLEASE CONTACT:
Name: _____________________________________
Relationship: ______________
Address: _______________________________________ City: ___________________
State: _________ Zip Code: _____________
Country: __________
Day phone: (_____) - _____- ______ Night Phone: : (_____) - _____- _______
The following information may be needed by any hospital or medical practitioner not having access to your medical history:
Allergies to medicine, food, etc. ______________________________________________________________
Medication being taken: _____________________________________________________________________
Date of last tetanus shot:
Physical Impairments:
Other: ________________________________________________________________
PERSONAL PHYSICIAN
Name: _____________________________________
Relationship: ______________
Address: _______________________________________ City: ___________________
State: _________ Zip Code: _____________
Country: __________
Day phone: (_____) - _____- ______ Night Phone: : (_____) - _____- _______
PERSONAL HEALTH INSURANCE COVERAGE:
Company: ________________________________ Policy Number: ______________
Insurance Agent: ______________________ Agent’s Phone: ___________________
Primary Beneficiary: _____________________
Relationship: ________________
Secondary Beneficiary: ____________________ Relationship: __________________
RELEASE AND WAIVER OF LIABILITY
EL Salvador and Guatemala Mission Trip
Important: Each participant must have a signed “Release and Waiver of Liability” on file.
Complete this form now in order to be considered and print all information in blanks
provided.
This Release and Waiver executed on this day _____/_____/_________(date) by
________________________ (participant’s name) and in effect for one full calendar year from this date.
I, the Participant, desire to participate in a mission trip to El Salvador and Guatemala this coming summer in
order to grow in faith and accompany the Lutheran Church of El Salvador. I, the participant, understand that the
activities may include but are not limited to: traveling to and from other countries, traveling to and from other
cities and towns, consuming food and living in accommodations available and provided in the foreign countries,
working with the Lutheran Church, assisting at a homeless shelter, participating in a march for human rights, and
other church activities.
I hereby freely and voluntarily, without duress, execute this Release under the following terms:
1) Waiver and Release. I, the Participant, release and forever discharge and hold harmless the leaders of
this mission trip (Pastors Anna-Kari and Kristian Johnson, Julie Jacks), Pilgrim Lutheran Church,
Chicago, IL; Resurrection Lutheran Church, Redondo Beach, CA; and their successors and assigns
from any and all liability, claims, and demands of whatever kind and nature, either in law or in equity,
which arise or may hereafter arise from my participation in this mission trip.
I understand and acknowledge that this Release form discharges the leaders of this trip from any liability or
claim that I, the participant, may have against them with respect to bodily injury, personal injury, illness,
death, or property damage that may result from my participation with a Thrivent Builds Worldwide work
team.
I also understand that the leaders nor any church involved is assuming any responsibility for or obligation to
provide financial assistance or other assistance, including but not limited to: medical, health, or disability
insurance, in the event of injury, illness, death, or property damage.
2) Medical Treatment I, the volunteer, hereby release and forever discharge the leaders of this trip from
any claim whatsoever which arises or may hereafter arise on account of any first-aid treatment or other
medical services rendered in connection with an emergency during my time in El Salvador and
Guatemala.
3) Assumption of the risk. I, the participant, hereby expressly and specifically assume the risk of injury
or harm in these activities and release the leaders and churches involved from all liability for injury,
illness, death, or property damage resulting from the activities of my time with the mission group.
4) Photographic release. I, the participant, grant and convey unto the leaders and congregations involved
all right, title, and interest in any and all photographic images and video or audio recordings made by
Habitat and Thrivent Financial during my work with this mission group.
To express my understanding of this release, I sign here with a witness.
Name of Volunteer (please print): _____________________________________
Address: _____________________ City: _________________ State: _______ Zip Code: ___________
Signature: _____________________________
Date: ________________
Name of witness (please print): ____________________________
Home Phone: (_____) ______ - _______ Work Phone (_____) ______ - _______
Signature: _____________________________
Date: ________________
RELEASE AND WAIVER OF LIABILITY of a MINOR
EL Salvador and Guatemala Mission Trip
Important: Each participant must have a signed “Release and Waiver of Liability” on file.
Complete this form now in order to be considered and print all information in blanks
provided.
This Release and Waiver executed on this day _____/_____/_________(date) by
________________________ (participant’s name), a minor child (the participant) and ____________________
and _____________________ the parents having legal custody and/or the legal guardians of the Volunteer (the
“Guardians”) and in effect for one full calendar year from this date.
The participant and guardians desire that their child participate in a mission trip to El Salvador and Guatemala
this coming summer in order to grow in faith and accompany the Lutheran Church of El Salvador. The
participant and guardians understand that the activities may include but are not limited to: traveling to and from
other countries, traveling to and from other cities and towns, consuming food and living in accommodations
available and provided in the foreign countries, working with the Lutheran Church, assisting at a homeless
shelter, participating in a march for human rights, and other church activities.
The participant and guardians hereby freely and voluntarily, without duress, execute this Release under the
following terms:
1) Waiver and Release. The participant and guardians release and forever discharge and hold harmless
the leaders of this mission trip (Pastors Anna-Kari and Kristian Johnson, Julie Jacks), Pilgrim Lutheran
Church, Resurrection Church, and their successors and assigns from any and all liability, claims, and
demands of whatever kind and nature, either in law or in equity, which arise or may hereafter arise from
the participant’s participation in this mission trip.
The participant and guardians also understand and acknowledge that this Release form discharges the leaders
from any liability or claim that the participant, may have against them with respect to bodily injury, personal
injury, illness, death, or property damage that may result from my participation with this mission group.
The participant and guardians also understand that the leaders nor any church involved is assuming any
responsibility for or obligation to provide financial assistance or other assistance to the participant, including
but not limited to: medical, health, or disability insurance, in the event of injury, illness, death, or property
damage.
2) Medical Treatment The participant and guardians hereby release and forever discharge the leaders of
this trip from any claim whatsoever which arises or may hereafter arise on account of any first-aid
treatment or other medical services rendered in connection with an emergency during the participant’s
time in El Salvador and Guatemala.
3) Assumption of the risk. The participant and guardians hereby expressly and specifically assume the
risk of injury or harm in these activities and release the leaders and churches involved from all liability
for injury, illness, death, or property damage resulting from the activities of the participant’s time with
the mission group.
4) Photographic release. The participant and guardians grant and convey unto the leaders and
congregations involved all right, title, and interest in any and all photographic images and video or
audio recordings made by Habitat and Thrivent Financial during the partcipant’s work with this mission
group.
To express our understanding of this release, the participant and guardians sign here with a witness.
Name of Volunteer (please print): _______________________Signature: ______________________________
Address: ____________________ City: ____________ State: ___ Zip Code: ________ Date: ____________
Name of Guardian (please print): _______________________Signature: ______________________________
Address: ____________________ City: ____________ State: ___ Zip Code: ________ Date: ____________
Signature: _____________________________
Date: ________________
Name of Guardian (please print): _______________________Signature: ______________________________
Address: ____________________ City: ____________ State: ___ Zip Code: ________ Date: ____________
Parental Authorization for Treatment of a Minor Child
I, ________________________, am the parent or legal guardian having custody of ____________________, a
minor child. As such a parent or legal guardian, I hereby authorize and appoint Pastors Anna-Kari and Kristian
Johnson, adults in whose care the minor child has been entrusted as my agent to act for me with respect to my
minor child, __________________, and in my name in any way I could act in person to make any and all
decisions for me with respect to my minor child, _____________________, concerning my minor child’s
personal care, medical treatment, hospitalization, and health care and to require, withhold, or withdraw any type
of medical treatment or procedure, including X-ray examination, anesthetic, medical, or surgical diagnosis or
treatment which may be rendered to my minor child under the general or special supervision and on the advice of
any physician or surgeon licensed to practice in the state in which treatment is sought. My agent shall have the
same access to my minor child’s medical records that I have, including the right to disclose the contents to
others.
Parent or Guardian: (signature) ___________________________________________ Date: ____________
Parent or Guardian: (signature) ___________________________________________ Date: ____________
THIS RELEASE AND WAIVER OF LIABILITY FOR MINORS AND PARENTAL AUTHORIZATION FOR
TREATMENT OF A MINOR CHILD sworn to and subscribed before me by:
___________________________, and _____________________, the parents or legal guardians of
____________________, a minor child, this _______ day of _____________, 20___.
Notary Public Name: ______________________________________ My commission expires: ___________
Note: