2019 BLUE Missions Chaperone Application
Email address *
Chaperone's Name *
Your answer
Gender *
Email Address *
Your answer
Phone Number *
Your answer
Mailing Address *
Your answer
Date of Birth *
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T-Shirt Size *
Emergency Contact Name *
Your answer
Relationship to Applicant *
Your answer
Emergency Contact Phone Number *
Your answer
Emergency Contact Email *
Your answer
Full Name as it Appears on your Passport *
Your answer
Passport Number *
Your answer
Expiration Date on Passport *
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What is your state of residence (according to your driver's license)? *
Your answer
Please select all the weeks in 2019 that you are available to chaperone: *
Required
Are you staff at one of the schools below? *
If you have a preference, what high school would you like to chaperone for?
Your answer
Do you have a child participating on one of our 2019 service trips? *
If yes, what is their name and what trip are they participating on?
Your answer
Medical Information
Your response on this form certifies that your statements below are true. BLUE Missions Group reserves the right to refuse participation at the volunteer’s expense due to misrepresentation of medical and biographical information. Please note that personal medical information may be submitted to BLUE leaders to assist with any health related issues while on the trip.
Have you ever been medically diagnosed with any of the following conditions? (Check all that apply.) *
Required
List any major accidents, illnesses or operations you have had in the past five years. *
Your answer
List any/all physical/mental limitations or medical conditions that may restrict your ability to climb/carry equipment/perform manual labor on this expedition. *
Your answer
List any/all medications (including prescription medication) that you will be taking on this trip and why: *
Your answer
List any/all allergies to food and/or medication: *
Your answer
Dietary Restrictions *
Background Information
Job Title *
Your answer
Company Name *
Your answer
Company Address *
Your answer
Are you familiar with standard first-aid and current CPR techniques? *
Do you carry any medical insurance? *
At BLUE Missions, chaperones are a large part of our organization and the way that we lead service trips. The questions below allow us to get to know you better. Please take your time answering them. Be as detailed as you would like.
Languages Spoken *
Required
Have you ever traveled abroad? *
Have you participated on any short-term mission trip in the past? Do you have experience being a chaperone? (Explain) *
Your answer
Are you a registered volunteer with the Miami-Dade County Public School System or VIRTUS? *
Your answer
In a paragraph, please tell us why you would like to participate on a BLUE trip? What do you hope to gain from this experience? *
Your answer
Have you ever been convicted or pled guilty or no contest to a charge involving any offense against a minor/sexual offense/felony? *
Picture & Video Release
I hereby grant permission to the rights of my images, likeness and sound of my voice as recorded on audio or video without payment or any other consideration. I understand that my photographs or videos may be edited, copied, exhibited, published or distributed and I waive the right to inspect or approve the finished product wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of my image or recording.
I have read and agree to the Picture and Video Release statement above. *
Code of Conduct Contract
I acknowledge and understand that I will be working in a foreign country and that I will follow all instructions, rules, and regulations on appropriate behavior in the particular foreign country where I volunteer. This will include but not be limited to the use of alcohol, drugs, cigarettes, profanity, sexual comments, or a romantic relationship with anyone while on this trip. I acknowledge and understand that violation of any rules and regulations are grounds for immediate removal and return to the United States at my expense.
I have read and agree to the Code of Conduct Contract statement above. *
Electronic Signature *
Your answer
Today's Date *
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A copy of your responses will be emailed to the address you provided.
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