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Name* First Last Birthday* MM slash DD slash YYYY Gender* Male Female Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email* Home Church Pastor's Name Church Telephone NumberTrip DateChoose DateDecember 3-7, 2019March 28- April 4, 2020June 13-19, 2020June 20-27, 2020July 25 - August 1, 2020October 17-24Approved Custom DatePassport InformationYour Passport Number Passport Issuing Country Passport Expiration Date MM slash DD slash YYYY PASSPORT EMAIL PLEASE COPY THE PAGE OF YOUR PASSPORT THAT HAS YOUR PICTURE AND EMAIL TO LINDA CRAWFORD AT... LINDA@OPENDOORHAITI.ORG PLEASE STATE YOUR FULL NAME (AS LISTED IN YOUR PASSPORT) WHEN EMAILING PASSPORT PAGES.Your Weight (For Airline Purposes)* Please List Your Top Skills For Use on the Mission FieldOccupation WHOM SHOULD WE CONTACT IN CASE OF EMERGENCY?* EMERGENCY CONTACT PHONE NUMBER*HOW DID YOU HEAR ABOUT OPEN DOOR HAITI? FRIEND CHURCH WEB SEARCH EVENT DIRECT MAIL OR EMAIL OTHER T-SHIRT SIZE*SMLXLXXLMedical Information/Release (PUT "N/A" IF DOESN'T APPLY)PHYSICIAN NAME PHYSICIAN PHONEFAMILY INSURANCE COMPANY POLICY NUMBER IMMUNIZATIONS TETANUS TYPHOID HEPATITIS A HEPATITIS B OTHER IMMUNIZATIONS ARE YOU TAKING MALARIA MEDICATION? Yes No IF SO, WHICH MEDICATION? BLOOD TYPE (IF KNOWN) IN THE PAST HAVE YOU SUFFERED ANY OF THE FOLLOWING? (CHECK ALL THAT APPLY) ASTHMA SINUSITIS KIDNEY TROUBLE HEART TROUBLE BRONCHITIS DIABETES DIZZINESS STOMACH UPSET HAY FEVER SPECIFIC ALLERGY EXPLANATIONPREVIOUS OPERATIONS OR SERIOUS ILLNESSALL CURRENT MEDICATIONS SPECIAL DIET (BE SPECIFIC)Waiver of Liability and Consent CLICK HERE TO READ THE WAIVER OF LIABILITY AND CONSENTHEREBY I SIGN THE WAIVER OF LIABLITY AND CONSENT* I AGREE AND SIGN THE WAIVER Code of Conduct CLICK HERE TO READ THE CODE OF CONDUCTHEREBY I SIGN THE CODE OF CONDUCT AGREEMENT* I AGREE TO THE CODE OF CONDUCT Statement of Faith CLICK HERE TO READ THE STATEMENT OF FAITHOPEN DOOR HAITI STATEMENT OF FAITH* I HAVE READ THE OPEN DOOR HAITI STATEMENT OF FAITH SPELL OUT YOUR NAME (ELECTRONIC SIGNATURE) Security DepositI UNDERSTAND MY DEPOSIT IS NON-REFUNDABLE FOR THIS TRIP* YES PAYMENT CHOICE* Electronically Send by mail Amount* Mail payment to: Open Door Haiti P.O. Box 950458 Lake Mary, FL 32795 Credit Card* American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Expiration Date Month Month010203040506070809101112 Year Year20252026202720282029203020312032203320342035203620372038203920402041204220432044 Security Code Cardholder Name
