FRIENDS OF CHIMBOTE – MISSION GROUP APPLICATION FORM
Dear Group Leader,
Thank you for your interest in leading a group to our mission in Chimbote, Peru. Your willingness to visit and
witness the poverty in Chimbote and share this opportunity with your group members exemplifies your
compassion and interest, and we look forward to getting to know you further.
Our primary goals for all mission visitors and groups are:
 That the visit will be meaningful and safe.
 That each person will obtain insight and education related to poverty and how Friends of
Chimbote and its’ partner in Chimbote, Asociación Civil Apoyo Familiar (ACAF) are helping
meet the social ministry needs of Our Lady of Perpetual Help parish.
 To avoid doing for the poor of Chimbote what they (the poor) have the capacity to do for
themselves.
In addition we ask that:
 Group leaders work closely with Friends of Chimbote and ACAF and utilize the infrastructure in
place to ensure that the benefits and/or projects related to the visit are in direct alignment with
current goals and needs that have been determined by Friends of Chimbote and ACAF.
 If a group wishes to utilize the services of independent locals, the locals will work under the
direction of ACAF leadership staff to ensure that the goals outlined by ACAF are met.
 All groups will participate in mission and ACAF orientation within the first few days of the visit.
Orientation will include education about current and priority programs and projects in place.
 It is understood that new programs and projects are not being sought. Rather, visitors are
encouraged to respect and support the existing programs and projects as identified by ACAF.
Upon completion of this application, please save it as a Microsoft Word (“.doc”) document and email it to
Friends of Chimbote at: support@friendsofchimbote.org a minimum of 4 months prior to your desired
arrival date in Chimbote keeping in mind that there are many requests for group visits and there are no
guarantees until your application has been approved. If you prefer, you may fax the application to our
Fargo, ND office 701-364-0993.
Thank you for completing this application in its entirety.
Friends of Chimbote
Fargo, ND and Chimbote, Perú
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FRIENDS OF CHIMBOTE – MISSION GROUP APPLICATION FORM
Group Information
Prior to completion of this application, please visit our website www.friendsofchimbote.org to become familiar
with who we are, and our organization in Chimbote (ACAF) and review the Trip Handbook found on the “Visit
Chimbote” page.
1. A Group Leader must be assigned and he/she will work closely with Friends of Chimbote to plan the trip.
Group leaders stay at the mission compound in the dormitories with their group members and bear overall
responsibility for group members.
2. Name of Group Leader (must be minimum of 21 years of age):
3. Group Leader Mailing Address:
4. Group Leader Email Address:
5. Group Leader Preferred Phone Number:
6. The recommended length of stay for a group at the mission is 5-7 nights, with the maximum number of
nights that we can host a group being 7. Please provide the preferred date(s) for your groups mission visit:
(Month, dates, and year)
7. Is there a secondary time period if your first choice of dates is already taken?
8. How did you hear about the mission?
9. Have you visited the mission previously and if so, date(s):
10. Is this group affiliated with a parish, congregation, school/university or other organization of some kind and
if so, explain:
11. Please describe your groups primary goal(s) for this mission trip:
12. Our mission in Chimbote serves the 15 barrios of Our Lady of Perpetual Help parish. Describe the
population/people that you wish to serve while in Chimbote and if it extends beyond mission barrios,
please explain:
13. Is this a “Medical Mission Group?”
Yes
No
If yes, please contact Friends of Chimbote to receive specific medical mission related guidelines. After
review of those guidelines, describe the proposed medical services and/or project while your group is at
the mission and how it will compliment and/or provide services that are not currently available within our
existing medical program. (Attach separate document if more space needed.)
14. In the “Trip Handbook” located on our website, pages 15-16 describe suggested activities and projects
available at the mission. Please describe the activities, program and/or projects that your group wishes
to participate in while at the mission and how they align with the mission and vision of Friends of
Chimbote and ACAF. (Attach separate document if more space needed.)
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FRIENDS OF CHIMBOTE – MISSION GROUP APPLICATION FORM
15. A daily rate of $15.00 per person per day is charged for room and board. Do you agree to pay this fee
to Friends of Chimbote a minimum of 3 weeks in advance of your group arrival in Chimbote?
Yes
No
16. A one page excel spreadsheet with required “Visitor Information” for all group members must be
completed by the group leader and submitted to Friends of Chimbote a minimum of 4 weeks in advance
of the group’s arrival in Chimbote. Do you agree to facilitate this with your group and submit the
spreadsheet with the required data within the required timeline?
Yes
No
17. To provide an optimal experience for mission groups within the infrastructure in place at the mission a
maximum group size of 25 is allowed. What is the estimated size of your group? _______
18. Typically the minimum age requirement for group members is 15 years of age. What is the expected
age range of group members?_______ What is the anticipated male/female ratio?_________
19. Describe any non-mission related activities or side trips, if any that your group plans to participate in
while in Chimbote or Peru and the travel agent/company that you are working with:
Drug & Alcohol Policy
Friends of Chimbote believes in healthy lifestyle modeling at the mission Chimbote. That means absolutely no
illegal drugs are permitted during the visit. In addition, no alcohol will be consumed by those under 21 years of
age and if those age 21 and over choose to consume alcohol it will be in moderation. Lastly, tobacco use is
discouraged and if used, will only be in specific designated smoking areas. Absolutely no smoking is allowed near
an estera home or structure. On behalf of your group do you agree to these guidelines and will you enforce them
while in Chimbote?
Yes
No
Conclusion
By completing this information form, I understand and agree that I have read and understand all questions and
notices in this form and confirm that all answers given, statements made and information provided are true and
complete to the best of my knowledge and belief. Any false statement, misrepresentation or omission of any
relevant fact may be justification for refusal of visitor admittance.
X: ____________________________
Signature or e-signature of group leader
__________________
Date
Thank you for providing this information. Generally an application will be processed within 10 – 15
business days of receipt. If you have any questions about the status of your application call the
Friends of Chimbote office located in Fargo, ND 701-364-0162.
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