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Participant Information Sheet
the form must be completed in full. Please answer all questions.
Name *
Your answer
Month and Year of Trip *
Address *
Your answer
Home Phone
Your answer
Work Phone
Your answer
Cell Phone *
Your answer
Birth Date (month/day/year) *
Your answer
Birth Place *
Your answer
Name on Passport (must be exactly as shown on your passport application) *
Your answer
Passport Number (Be sure your team leader has a copy of your passport) *
Your answer
Expiration Date *
Your answer
If not a US citizen, list citizenship country
Your answer
Country/State/City of Issue *
Your answer
Travel Insurance Company *
Your answer
Travel Insurance Policy Number *
Your answer
Marital Status *
Your answer
Emergency Contact *
Your answer
Relationship to Emergency Contact *
Your answer
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. *
Your answer
Parent/Guardian Signature for Photo Release if a minor
Your answer
Date Signed for Photo Release *
Your answer
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