Annual HOM Trip Application
Email address *
Name *
Last Name, First Name, MI
Your answer
Street Address *
Your answer
City & State *
Your answer
Zipcode *
Your answer
Phone *
xxx-xxx-xxxx
Your answer
Birth Date *
MM
/
DD
/
YYYY
Email Address *
Your answer
Church Name *
Your answer
Passport # *
Your answer
Issue Date *
MM
/
DD
/
YYYY
Expire Date *
MM
/
DD
/
YYYY
Issue Authority *
Your answer
Nurse License #
Your answer
Expire Date
Your answer
Issue State
Your answer
Emergency Contact Name *
Your answer
Address, City, State *
Your answer
Emergency Phone *
xxx-xxx-xxxx
Your answer
Mission Team
Specific Abilities
Your answer
Agreement
By completing this application for the annual Haiti Outreach Mission (HOM) trip, (a) I AGREE to purchase medical/evacuation insurance covering the mission dates, plus an additional week in case of hospitalization in Haiti; (b) I WILL provide the name and policy contract information numbers to HOM in case of emergency while traveling in Haiti during mission dates; and (c) I WILL be responsible to update my vaccinations for travel in Haiti as identified by a medical travel clinic, the Center for Disease Control (CDC), or your physician.
A copy of your responses will be emailed to the address you provided.
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