Feedback Form Test

Name EXACTLY as it appears on passport *

First

Middle

Last

Street Address *

City

State

Zip

Best Contact Phone *

Alt Phone *

Email *

Group attending with *

Trip dates *

Shirt size *

Passport # *

Expiration date *

Issue date *

Date of birth *

Citizen of what country *

Choose one *

Male
Female

Emergency contact name *

First

Last

Relationship to you *

Address *

Phone *

Alt Phone

Email *

List any health issues (including environmental, food, and medication allergies) *

Prescription medications (please include dose and frquency) *

Do you speak spanish? *

Have you participated in any mission trips before? If yes, where did you go and what did you do? *

What gifts or talents do you have? *

Have you ever been convicted of a crime? If yes, please describe below. *

Participant e-signature *

(If less than 18 years old, please contact your team leader for a form). By clicking submit, I attest that all information I have provided is accurate to the best of my knowledge. I do, hereby, release Building Believers in Christ, its employees and trip directors, its board members, and its donors from any liability associated with participation in this activity. I also understand that I will be responsible for any medical and/or travel expenses in the event of an illness and/or injury. I understand that I am participating at my own risk.

Date *