Returning Trip Agreement

This application is for people who have ALREADY made a trip to Haiti with ODH. This Agreement Form must be submitted along with your non-refundable deposit to secure your spot. The balance of your mission trip fee MUST be paid no later than 30 days prior to your trip date.

Trip Dates Confirmed (required)

I have confirmed my trip date availability with my team leader or Open Door Haiti staff and understand my deposit of is NON-refundable.

*The Name on your Returning Trip Agreement Form MUST match your Passport exactly.

Your First Name (required)

Your Last Name (required)

Birthday (required)

Gender (required)
MaleFemale

Address (required)

Address Line 2

City (required)

State (required)

Postal Code (required)

Email (required)

Phone Number (required)

Trip Date (required)

If you checked 'Approved Custom Dates' - manually enter the dates of your trip AND team leader.




Passport Information

Your Passport Number

Passport Issuing Country

Passport Expiration Date

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) (required)

Whom should we contact in case of emergency? (required)

Emergency contact phone number (required)

Emergency contact email




Medical Information/Release

(Put "n/a" if doesn't apply)

Physician Name

Physician Phone

Family Insurance Company

Policy Number

Immunizations
TetanusTyphoidHepatitis AHepatitis B

Other Immunizations

Are you taking malaria medication?
YesNo

If so, which medication?

Blood Type (if known)

In the past have you suffered any of the following? (Check all that apply)
AsthmaSinusitisKidney TroubleHeart TroubleBronchitisDiabetesDizzinessStomach upsetHay Fever

Specific Allergy Explanation

Previous operations or serious illness

All Current Medications

Special Diet (be specific)

Waiver of Liability and Consent

Click here to read the Waiver of Liability and Consent

HEREBY I SIGN THE WAIVER OF LIABLITY AND CONSENT
I agree and sign the waiver

Code of Conduct

Click here to read the code of conduct

HEREBY I SIGN THE CODE OF CONDUCT AGREEMENT
I agree to the code of conduct

Statement of Faith

Click here to read the statement of faith

OPEN DOOR HAITI STATEMENT OF FAITH
I have read the Open Door Haiti Statement of Faith

Security Deposit

I WILL SEND MY NON-REFUNDABLE DEPOSIT FOR THIS TRIP
Yes


Spell out your name (electronic signature)(required)


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