Puente de Amistad Team Member Application: Minor

Puente de Amistad Team Member Application

Minor Application
Full Name of Minor *

First Name Last Name
Cellular Phone Number of Minor *

Area Code Phone Number
Full Name of Minor Guardian/Parent *

First Name Last Name
Cellular Phone Number of Guardian/Parent *

Area Code Phone Number

Minors Address *

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

Minor's Home Phone Number *

Area Code Phone Number
E-mail of Minor *
Birth Date of Minor: *

Month Day Year
Date
Age of the Minor: *
Minor's Gender: *

Male Female
Please, upload a current photo of Minor. ( Current: within the last 5 days.)

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Church Information
Church Full Name
Church Phone Number

Area Code Phone Number
Church E-mail
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
Minor's 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: *
Do you have a passport" *

YES NO
Date of expiration on Passport:

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

YES NO
Date of expiration on Passport Card:

Month Day Year
Date
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)

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A good copy of your Passport is in 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 Book or 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 Good Fair Poor
If your answer was anything other than "Excellent" please explain why:
List all medications that you are taking and their purpose:
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

Minor Waiver of Liability
Print Name of Minor *

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).
Minor's Signature: Waiver of Liability *
Print Guardian/Parent 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).
Signature of Guardian/Parent Name *
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