Trip Application - A Door To Hope

BEFORE YOU FILL OUT THIS APPLICATION YOU MUST CALL THE OFFICE, AT 615-331-4600,
TO CONFIRM OPEN SPOTS FOR THE DATE YOU’RE REQUESTING!

each application requires a $125, non-refundable, deposit for your trip. after completing the application you will be prompted to choose a payment method, either paying online today or sending in a check.

Please Acknowledge the following statement before completing application.

THE COST OF THE TRIP IS $650 PER PERSON, PLUS AIRFARE AND SUPPLIES. THERE IS A NON-REFUNDABLE, NON-TRANSFERABLE, DEPOSIT OF $125 THAT IS DUE UPON APPLYING. IF THIS DEPOSIT IS NOT RECEIVED WITHIN TEN DAYS AFTER APPLICATION IS COMPLETED, THE DEPOSIT WILL THEN GO UP TO $150 AND LATE FEE WILL NOT BE APPLIED TOWARD BALANCE. THE COST OF THIS ONE WEEK TRIP WITH A DOOR TO HOPE IN HAITI COVERS YOUR FOOD, LODGING, TRIP INSURANCE AND TRANSPORTATION DURING THE WEEK IN HAITI.*

I UNDERSTAND THE COSTS OF THIS TRIP. I ALSO UNDERSTAND THAT MY DEPOSIT IS NON-REFUNDABLE, NON TRANSFERABLE AND IF IT IS LATE I ALSO UNDERSTAND THAT A LATE FEE OF $25 IS DUE AND WILL NOT BE APPLIED TOWARD MY FINAL BALANCE.

Please complete the application below:

I am registering for . . . *

Name on Passport *

First

Last

Trip Date and Location *

Are You An Advocate With A Door To Hope? * Yes No

YOUR HOME ADDRESS *

Street Address

Address Line 2

City

State

Zip

GENDER * Male Female

OCCUPATION *

BIRTHDAY *

YYYY

EMAIL ADDRESS *

PHONE NUMBER *

Shirt Size *

PASSPORT NUMBER *

PASSPORT ISSUING COUNTRY *

PASSPORT ISSUANCE DATE *

YYYY

PASSPORT EXPIRATION DATE *

YYYY

CHURCH / ORGANIZATION NAME *

HOW DID YOU HEAR ABOUT A DOOR TO HOPE *

EMERGENCY CONTACT INFO *

First Name

Last Name

Relationship

Phone Number

Street Address

Address Line 2

City

State

Zip

DO YOU HAVE ANY MEDICAL, DIET OR PHYSICAL RESTRICTIONS OR CONCERNS? HOW IS YOUR GENERAL HEALTH? *

DO YOU SPEAK ANY FOREIGN LANGUAGES? IF SO, LIST THEM BELOW *

PLEASE LIST YOUR TOP THREE SKILLS FOR USE ON THE MISSION FIELD*

AGREEMENT: BGM - A DOOR TO HOPE IS NOT TO BE HELD RESPONSIBLE FOR EXPENSES INCURRED BY ILLNESS OR ACCIDENT WHILE OR SUBSEQUENT TO MY STAY IN HAITI. I AGREE TO PROVIDE MY OWN PERSONAL ACCIDENT/HEALTH INSURANCE APART FROM A DOOR TO HOPE TRAVELERS INSURANCE. *
Agree I Do Not Agree

WAIVER AND RELEASE AGREEMENT

Is Trip Member Under 18?

All minors, under 18, must include an electronic adult signature

Waiver and Release:

A. As a condition of being permitted to travel with BGM - a door to hope and participate in a mission trip to the Country of Haiti, during the week of your trip in Haiti, the undersigned hereby:
1. Agrees to assume all normal and foreseeable risks associated with travel to, from and within the Country (including but not limited to natural disasters, terrorism, political unrest, and contraction of illness) and releases Company and its affiliates from any responsibility for such risks;
2. Acknowledges that the carriers, hotels and other suppliers (the “suppliers”) providing services in connection with the missions trip are independent contractors and are not agents, employees or representatives of, or joint venturers with, the Company or its affiliates and releases Company and its affiliates from any responsibility for the actions or omissions of such suppliers;
3. Agrees that the Company shall have no liability for any personal injury, property damage or other loss, accident, delay, inconvenience, or irregularity which may be caused by (a) any wrongful, negligent or unauthorized acts or omissions on the part of any of the suppliers or their agents, (b) any defect in or failure of any vehicle, equipment or instrument owned, operated or otherwise used by any supplier, or (c) any wrongful or negligent acts or omissions on the part of any other party not under the control of the Company;
4. Releases the Company, its officers, directors, employees, agents and representatives from any claims whatsoever relating to the missions trip to the Country;
5. Agrees not to sue or otherwise hold the Company responsible for any injury, damage, or loss resulting to the undersigned or the undersigned’s property in connection with the undersigned’s participation in the missions trip to the Country;
6. Accepts full responsibility for luggage and other belongings brought on the missions trip by the undersigned;
7. Agrees to submit any dispute, claim or cause of action arising out of the undersigned’s participation in the missions trip to the Country solely to a Christian arbitration panel, agreeing that lawsuits among and between Christians is prohibited by Scripture; and
8. Agrees to be responsible for any injuries, damages or losses caused by the undersigned while the undersigned is traveling with representatives of the Company or while the undersigned is in the Country.
B. The undersigned acknowledges that the Company has recommended that the undersigned obtain a physical examination and proper inoculations prior to going on the mission trip.
C. The undersigned acknowledges that he/she has been informed that United States citizens traveling outside of the United States are required to carry documentation of United States citizenship, which may include a valid passport or notarized copy of the citizen’s birth certificate with a raised seal, and a valid picture I.D. (such as a driver’s license).

WAIVER AGREEMENT *

Agree I Do Not Agree

APPLICATION SUBMISSION AND NEXT STEPS

Once you submit your application & deposit, you will receive an email from Matt, our Missions Director, confirming your spot on the trip. You will then want to book your travel. For safety and logistical purposes, ALL TEAM MEMBERS must book their travel through

Janell at Safe Harbors, 1.800.344.5656 EXT. 6123.

This will assure that all members arrive together in Haiti. Please contact the BGM office if you have any questions about this policy.

Payment Options

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Amount You're Paying Today: $ Deposit Total: $ Remaining Balance: $

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