X - 2022 - Miami - August - Travel Registration

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I understand that I am completeing the travel registration for the Miami August 2022 Mission Trip.

Yes

Legal First Name

Middle Name(s)

Legal Last Name

Birthday (Month, day, year)

Gender

Female Male

Emergency Contact 1 (Full Name of someone NOT traveling with you)

Emergency Contact 1 (Relationship)

Emergency Contact 1 (Phone) and (Email)

Insurance Company Name

Group Number / Policy Number

Health Concerns / Allergies / Medication

Dietary Restrictions

Group or Church that you are traveling with

Group or Church Leader who is traveling with you

If I cancel my mission trip within 90 days of departure, my fundraising account balance cannot be applied to another trip on my behalf and will be used for mission work in the country in which I was scheduled to travel

I agree

I understand that all money given to Mentor Leaders is considered as a donation by the IRS and is NOT refundable

I agree

I hereby grant Mentor Leaders and any of its partners permission to use my likeness in a photograph, video or other digital media in any and all of its publications

I agree

This includes web-based publications, without payment or other consideration.

I hereby irrevocably authorize Mentor Leaders to edit, alter copy, exhibit, publish, or distribute these photos for any lawful purpose.

I agree

Additionally, I waive any right to royalties or other compensation arising or related to the use of the photo.

I agree

In addition, I waive any right to inspect or approve the finished product wherein my likeness appears.

I agree

I agree that all submitted information is correct and true. Mentor Leaders can seek medical attention on my behalf if I am unable to do so during travel with the organization.

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X - 2022 - Miami - August - Travel Registration

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