Trip Application – Give Hope Global

Select a trip*

Personal Information

Name*

First Last

Date of birth*

Age at start of trip*

You must be 18 or older to travel without a parent/guardian*

I am 18 or older
I am under 18

If you are under 18, please list the parent/guardian who will be with you on this trip

Gender*

Male
Female

Occupation

Are you a student?*

Yes
No

Grade/Level

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email*

Enter Email Confirm Email

Phone*

Passport Information

Important: You need to have a passport, valid for at least 6 months AFTER the last date of the trip. If you do not yet have a passport, you need to apply for one as soon as possible. If you are in the process of applying for a new passport, please enter 000000000 (9 zeros) in the Passport Number section, and for the dates, please enter today's date.

Full Name (exactly as is appears on your passport)

Passport Number*

Country of Citzenship*

Date of Issue*

Expiration date*

Trip Information

Areas of interest and special skills*

Dental
Medical
Construction
Teaching
Art
Sports
Other

Pick at least one that may be of interest to you.

If you selected other in the above question, please explain

Is this your first Give Hope Trip?*

Yes
No

Do you have any medical training?*

Yes
No

How did you hear about Give Hope Global?*

Why Haiti/Ghana?*

If you selected other in the above question, please explain

What do you feel you will be able to contribute to Give Hope and the people we serve?*

Please list all languages that you speak*

Meals*

I agree
I disagree

I understand that Give Hope Global will provide two meals a day and that I am responsible for bringing my own nonperishable snacks. Please know that we are unable to provide meals to accommodate dietary restrictions/preferences. I also understand that there may not be opportunity or availability to purchase special items in Haiti. As such, I agree to bring my own nonperishable foods with me to supplement the prepared meals in order to meet my own preferences. I further understand that this is at my own expense.

Health Information

Do you have any allergies?*

Yes
No

List any allergies*

Are you taking any medications?*

Yes
No

What medications are you currently taking and why?*

Are there any illnesses, surgeries or other health conditions that might affect your participation on this trip?*

Yes
No

Please include any further information*

Are you pregnant/think you might be pregnant?*

Yes
No

Do you have any of the following?

Chronic diseases
Chronic medications
Immune deficiencies
Autoimmune disease
HIV disease
Hospitalizations within the last 24 months
History of severe allergic responses or anaphylaxis
Chronic anticoagulant use
Psychiatric disease

Health Insurance

Physician's Name*

Physician's Phone*

Name of insured*

First Last

Insurance Carrier*

Policy Number*

Carrier Phone*

Emergency Contact

Name*

First Last

Primary phone*

Secondary phone

Email*

Relationship*

Additional Information

Please let us know if there is anything your team leaders should be aware of that was not in the application.

I understand that my $300 deposit is non refundable, as are all payments, as they are a donation to Give Hope Global. Please initial below:*

Mission Trip Application

Personal Information

Passport Information

Trip Information

Health Information

Health Insurance

Emergency Contact

You have Successfully Subscribed!