Personal and Medical Information for Volunteers

First Name

Last Name *

Address

Address 2

City

State

Zip/Postal Code

Home Phone

Mobile Phone

Marital Status

Spouses First Name

Spouses Last Name

Location of Trip

Dates of Trip

Shirt Size

Name Exactly As it Appears on Passport

Passport #

Country of Citizenship

Date of Birth

Medical Information

1. Information about any prescriptions I use:

2. I am allergic to:

3. Food Allergies, please note if you are a vegan or vegetarian:

4. My health insurance company is

Policy Number

5. Please provide other helpful health information, physical limitations, or concerns:

6. I consider myself healthy enough to fulfill my responsibilities on the mission team.

Yes

No

Consent

I give permission to receive emergency medical attention from a physician in the event of illness or injury.

Myself ( if over 18 )

Son

Daughter

Signed

Date Signed

Trip Insurance Information

GLOW (Go Love Our World) International, Org. will provide secondary accident and injury insurance for each volunteer during the mission trip. The following information is needed to secure this insurance:

Beneficiary Full Name

Relationship to Beneficiary

PARTICIPANT LIABILITY RELEASE FORM

Please read before signing, as this constitutes the agreement as a volunteer and the understanding of your working relationship as a volunteer with GLOW (Go Love Our World) International, Org.

I, acknowledge and state the following:
I understand that this work involves a risk of physical injury and often involves hard physical labor, heavy lifting, and other strenuous activity; and that some activities may take place on ladders and building other than ground level. I certify that I am in good health and physically able to perform this type of work. I understand that GLOW (Go Love Our World) International, Org has the right to refuse acceptance of any volunteer.

I understand that I am engaging in this project at my own risk. I assume all risk and responsibility for any damage or injury to my property or any personal injury, which I may sustain while involved in this project, and related medical costs and expenses.

In the event that my supervising organization arranges accommodations, I understand that they are not responsible or liable for my personal effects and property and that they will not provide lock up or security for any items. I will hold them harmless in the event of theft or for loss resulting from any source or cause. I further understand that I am to abide by whatever rules and regulations may be in effect for the accommodations at that time.

I herby grant permission to GLOW (Go Love Our World) International, Org., at its sole discretion, to publish or otherwise use any photos or videos of me for all legitimate purposes, in any and all of its publications, including website entries, without additional consideration or compensation.

By my signature, I release, discharge and forever hold, GLOW (Go Love Our World) International, Org, together with their officers, agents, servants, and employees, harmless from any and all causes of action arising from my participation in this project, and travel or lodging associated therewith, including any damages which may be caused by their negligence.

Signature

Date

Address

Address Line 2

City

Sate

Zip/Postal Code

Dates of Mission Trip Covered by this Liability Form

Person to Contact in Case of Emergency

Address

Address Line 2

City

State

Zip/Postal Code

Home Phone

Mobile Phone

Relationship