Puente de Amistad Team Member Application: Adult

Puente de Amistad Team Member Application

Adult Application
Team Member Full Name *

First Name Middle Name Last Name
Spouse's Full Name (N/A if not applicable)

First Name Middle Name Last Name

Team Member Current Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Team Member Phone Number (Home) *

Area Code Phone Number
Team Member Phone Number (Cell) *

Area Code Phone Number
Team Member E-mail *
example@gmail.com
Team Member Birth Date: *

Month Day Year
Date
Team Member Age: *
Team Member Gender: *

Male Female
Church Information
Church Full Name *
Church Phone Number *

Area Code Phone Number
Church E-Mail Address *
example@example.com

Church Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Team or Group Information
Team Leaders Name

First Name Last Name
Team Leaders E-mail
example@example.com
Team Name (What do you call your team?)
Emergency Contact Information
Emergency Contact Name: *
Relationship with Emergency Contact: *
Emergency Contact Phone Number: *

Area Code Phone Number
Personal Identification Questions
Mother's Maiden Name: *
Favorite Sport: *
Favorite color: *
Employer: *
City of Employment: *
Type of Work: *
Have you been on an overseas mission trip in the past? *

YES NO
If "YES", please list the places you have gone:
Do you have a Passport? *

YES NO
If "YES" to having a passport, what is the expiration date?

Month Day Year
Date
Do you have a Passport Card? *

YES NO
If "YES" to having a passport card, what is the expiration date?

Month Day Year
Date
Passport Number/ Passport Card Number:
Type a question
Please Note: A copy of your passport/passport card is a requirement of Puente de Amistad.

This is not a suggestion
Upload a copy of your passport book or passport card: (Passport Book: Needs to be of your photo and all the personal information)
*PDF format. *Needs to be of your photo and all your information
A good copy of your Passport is for your benefit! In the case of your passport or passport card being stolen or lost, you will need a copy to return to the United States of America. It is in your best interest to make the copy as professional as possible. Scanned Copies are preferred by the Border Guards.
If you do not have a Passport or a Passport Card you need to apply for one immediately. You will not be allowed re-entry into the United States without one of these forms of identification.
Medical Information
*This information will not be used to determine eligibility. It is important for your safety while you are on the trip.
My overall physical condition is: *

Excellent Fair Good Poor
If your answer was anything other than "Excellent", please explain why:
List all medications that you are taking and their purpose
Height: *
Weight: *
Doctor's Name *
Doctor's Phone Number

Area Code Phone Number
Date of last Tetanus Inoculation:

Month Day Year
Date
Health Insurance Carrier:
Health Insurance ID Number:
Group Number:
Is your medical insurance valid outside of the United States?

YES NO
Puente de Amistad Waiver of Liability

Adult Waiver of Liability
Team Member Covenant
Team Member's Printed Name *

First Name Last Name
*By signing in this box, you are stating that you have read the "Team Member Guide" and agree to follow all the rules, terms, policies, and pay agreements set forth by Puente de Amistad, either in the "Team Leader Manual", "Team Member Guide", or Puente de Amistad's (websitepdeamistad.org).
Team Member's Signature *
Date/Time *
Should be Empty:

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Puente de Amistad Team Member Application

Church Information

Team or Group Information

Emergency Contact Information

Personal Identification Questions

Medical Information

Puente de Amistad Waiver of Liability

Team Member Covenant