HONDURAS MISSION TRIP 2015
Mission Team Participant Application & Covenant
Trip dates: June 19-27, 2015
Please note: The Team Leaders and Spiritual Director will keep the information contained in this sheet
confidential.
Personal Information:
Name:
Address:
City:
Home Phone:
Other:
Birth Date:
Passport #:
Zip:
Cell Phone:
Email Address:
Marital status:
Country of Issue:
(PLEASE ATTACH A LEGIBLE PHOTOCOPY OF YOUR PASSPORT!)
*International Law: Your passport must be current through 6 mos. beyond the return date of the trip!
Place of Employment:
Address:
City:
Job Title/Description:
Zip:
In the event of an emergency, please notify this person (someone not going to Honduras)
Name:
Address:
City:
St:
Zip:
Day Phone:
Evening Phone:


I am a member of Church of the Incarnation
If you do not attend Church of the Incarnation, where do you worship?
Congregation/Church Name:
Spanish: How proficient are you? Speak _____________ Write______________
What specific skills do you have that you can contribute to our mission work?
 Construction
 Dental
 Education (Teaching, Art, Music)
 Spiritual
 Medical
 Other ____________________
HONDURAS MISSION TRIP 2015
Mission Trip Covenant
By signing this sheet, I understand and agree to meet the following requirements.
(Please check off each statement.)

Before and during the trip, I will commit myself to praying for our trip and to attending team meetings.

I will be responsible for obtaining financial support of my trip; including housing, meals, airfare, and
necessary immunizations (current Tetanus is required). Cost per person is $1500. I understand that the
application, covenant and the deposit of $200 are due at the time the application is submitted, and the
remaining balance of $1300 will be due no later than May 1, 2015. (Partial need-based grant applications are
available upon request.)

For the success of this mission and the well-being of the entire team, I will follow the authority of the Team
Leadership and Spiritual Director. I will cooperate with the Team Leaders’ directives and decisions
throughout the entire mission. The Team Leaders for this trip are Larry Tate and Melanie Brewer.

During the trip, I understand and will accept the conditions that may be different and uncomfortable
compared with those I am used to.

So that I will not hamper the team through avoidable illness, I will acquire all immunizations recommended
by my personal physician and will carefully follow the health guidelines established for the team.

I understand that I am expected to attend planning and informational meetings. The team retreat is Saturday,
May 2 and Packing Day is Saturday, June 6.

I understand that I will be part of a team, and I agree to work to promote team unity.

I understand that on this trip, I am a representative of Church of the Incarnation and will be expected to act in
ways becoming of Christians and, in this regard, will abstain from consuming excessive amounts of alcohol.

I certify that all information I have supplied in this application is true to the best of my knowledge.
Application and Deposit Deadline: March 1, 2015
I have attached:





Legible photocopy of my passport
Legible photocopy of both sides of my insurance card (personal insurance is required)
Completed Health History Form
Release Form
Non-refundable deposit of $200 (payable to COTI, Memo: Honduras Payment)
(Your application will be considered upon completion of all the above items.)
Signature: _________________________________ Date: _____________
Please return to:
Church of the Incarnation, attn: Mission and Outreach Department
3966 McKinney Avenue, Dallas, TX 75204
Email: outreach@incarnation.org or Fax: 214-528-7209
HONDURAS MISSION TRIP 2015
Release of All Claims, Waiver of Liability, and Assumption of the Risks
3966 McKinney Avenue, Dallas, Texas 75204-8211, (214)-521-5101
I, the undersigned, wish to participate, on a purely voluntary basis, in a mission/outreach activity of the Church of
the Incarnation (COTI). This mission/outreach activity includes travel to and works in the country of Honduras
from June 19 through June 27, 2015. I understand that this work is not for remuneration, but is volunteer/pro
bono work, and is likely to involve manual labor and/or construction work in which I may not have expertise or
skills. Never the less, I wish to participate, but understand that there is risk of injury which could arise in the
course of this trip and the work in which we will engage.
In consideration of being permitted to participate in this mission/outreach activity, I agree to be bound by this
agreement, which provides for release of claims, waiver of liability, and assumption of the risks. Further, I sign
this document and agree to its terms on behalf of myself, my heirs, executors and administrators, and assigns.
I hereby WAIVE ANY AND ALL CLAIMS, ACTIONS, AND CAUSES OF ACTION OF ANY TYPE OR
NATURE, I may now have or may have in the future against, and RELEASE FROM ALL LIABILITY, AND
AGREE NOT TO SUE, the COTI, its vestry, teachers, employees, volunteers, agents, successors, and assigns for
any accident, personal injury, death, property damage, damages of whatsoever kind or loss that I may suffer or be
otherwise entitled to under the law, as a result of my participation in the mission/outreach activity or any
activities related in any way thereto, due to any cause whatsoever, including, without limitation, negligence on
the part of the COTI, its agents, employees, or volunteers. Further, I agree to indemnify COTI for any and all
legal fees or cost that may be incurred in defending any lawsuit or claim I or my representatives may bring
against COTI related to the above described activities. Additionally, I will HOLD HARMLESS AND
INDEMNIFY COTI from any and all liability or claims for any loss, damage, injury, or expense brought by any
third party, which claims result in any way from my participation in any activity related in any way to the above
described mission/outreach activity.
Finally, should I be injured during the course of the mission/outreach activity, and I am unable to communicate
my authorization for medical treatment, I authorize COTI representatives to ask for medical treatment on my
behalf, should the same be necessary. To that end, I have provided to the COTI my medical insurance coverage
information.
Signed this ____day of ________, 2015.
Printed Name:
Address:
Phone:
Signature:
HONDURAS MISSION TRIP 2015
Health Registration Form
THE INFORMATION YOU PROVIDE IS CONFIDENTIAL. THIS COMPLETED FORM IS REQUIRED FOR YOU TO GO ON THE TRIP. THE HEALTH
HISTORIES OF THE TEAM MEMBERS WILL BE HELD BY THE TEAM PHYSICIAN AND WILL BE USED IN THE EVENT OF A MEDICAL EMERGENGY
ON THE MISSION TRIP. THIS IS STRICTLY FOR YOUR PROTECTION. (Please Print)
Today’s date:
Date Received:
MISSIONER’S INFORMATION
Missioner’s last name:
First:
 Mr.  Mrs.  Dr.
 Miss  Ms.
Middle:
Marital status (circle one)
Single / Mar / Div / Sep / Wid
Name as it appears on your passport:
Passport no.:
Birth date:
/
Blood Type:
Home phone no.:
(
State:
ZIP Code:
Employer:
Health Insurance Company:
)
Cell phone no.:
(
Occupation:
Sex:
M F
/
Street address:
City:
Age:
)
Email address:
Address:
Policy/Group #
Phone no.:
(
Are you insured by MedJet:
 Yes  No
 No health insurance
In case of emergency contact:
Name:
)
Address:
Relationship:
Best phone no. to reach:
2nd phone no. to reach:
(
(
)
Email address:
)
DOCTOR INFORMATION
(Please make a copy of your insurance card FRONT & BACK and attach to this form.)
Primary Health Care Provider:
Specialty:
Address:
Office phone no.:
(
Specialist provider #1 (Pulmonologist,
Cardiologist, etc) Name:
Specialty:
Address:
Office phone no.:
(
Specialist provider #3 (Endocrinologist,
Gastroenterologist, etc) Name:
Specialty:
Address:
)
)
Office phone no.:
(
)
If you have additional specialist please list on separate sheet of paper.
ALLERGY INFORMATION
Do you have any allergies to drugs, insects, food or other?  Yes
Drug Allergy #1
Drug Name:
Drug Allergy #2
Drug Name:
Insect Allergy #1
Insect Type:
 No *please note any anaphylactic
Reaction (hives, rash, anaphylaxis, etc.):
Reaction (hives, rash, anaphylaxis, etc.):
Reaction (hives, rash, anaphylaxis, etc.):
reactions you have had to any medications*
Insect Allergy #2
Insect Type:
Food Allergy #1
Food Type:
Food Allergy #2
Type:
Other Allergy #1
Type:
Other Allergy #2
Type:
Reaction (hives, rash, anaphylaxis, etc.):
Reaction (hives, rash, anaphylaxis, etc.):
Reaction (hives, rash, anaphylaxis, etc.):
Reaction (hives, rash, anaphylaxis, etc.):
Reaction (hives, rash, anaphylaxis, etc.):
Have any reactions ever required emergency room care?_______ Please list all allergies, if needed please use separate sheet of paper.
CURRENT HEALTH PROBLEMS
Problem #1 (i.e. diabetes, high blood pressure):
Medicine you are taking for this:
Problem #2 (i.e. diabetes, high blood pressure):
Medicine you are taking for this:
Problem #3 (i.e. diabetes, high blood pressure):
Medicine you are taking for this:
Please use additional sheets of paper for any additional problems you feel the Team Doctor(s) should know about.
 Asthma  Angina  Diabetes  Migraines  Ulcers  Bleeding abnormalities  Kidney Stones  Gall Stones  Seizures/Epilepsy
 Alcohol/drug Addition  Heart Disease  Hearing Disorder  Hypertension  Orthopedic Condition  Skin Disorder
 Eye/Vision Disorder
Psychiatric Disease:
 Bipolar  Schizophrenia  Anxiety  Depression
Blood Pressure average Reading:
 Thyroid Disease
 High/low Blood Pressure
Diabetic last HgbA,C:
Please explain any of the above:
Past Major Surgery #1
Date:
Surgery:
Past Major Surgery #2
Date:
Surgery:
Past Major Surgery #3
Date:
Surgery:
MEDICATIONS
Please list all PRESCIPTION medications you are take (including the ones listed above):
Name of Drug:
Dosage:
Frequency:
Purpose:
Please list all OVER-THE-COUNTER medications you are take (including the ones listed above AND vitamins):
Name of Drug:
Dosage:
Frequency:
Purpose:
Tetanus shot is required for all Mission Trips.
Tetanus Shot:
 Yes
Date:
Hepatitis A Inoculation:
 Yes  No
Date:
Typhoid Immunization:
 Yes  No
Date:
Hepatitis B Inoculation:
 Yes  No
Date:
Other information you would like us to know: