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Participant Information Sheet
the form must be completed in full. Please answer all questions.
Name *
Month and Year of Trip
Address *
Home Phone
Work Phone
Cell Phone *
Birth Date (month/day/year) *
Birth Place *
Name on Passport (must be exactly as shown on your passport application) *
Passport Number (Be sure your team leader has a copy of your passport) *
Expiration Date *
If not a US citizen, list citizenship country
Country/State/City of Issue *
Travel Insurance Company *
Travel Insurance Policy Number *
Marital Status *
Emergency Contact *
Relationship to Emergency Contact *
Your Signature for Photo Release: I give Zanmi Fondwa the right to use my picture/video, voice and/or testimony any form of promotional advertising materials. My signature (and signature of parent/legal guardian if I am under the age of 18) signifies authorization. *
Parent/Guardian Signature for Photo Release if a minor
Date Signed for Photo Release *
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