Amizade Participant Information and Medical Form (International)
Thank you for your interest in serving and learning with Amizade and our global network of community partners.

Please contact the Amizade office at 412-586-4986 or support@amizade.org for any questions.
Participant Name
First Name *
Your answer
Last Name *
Your answer
Group Program Number *
If you don't know your Group Program Number, contact your Group Leader or the Amizade Office.
Your answer
Program Location *
Where are you traveling?
Your answer
Birthdate *
mm/dd/yyyy
Your answer
Gender *
Preferred T-Shirt Size: *
Shirts are unisex, we do our best to honor size preference based on availability
Email 1 *
Your answer
Email 2
Your answer
Home Phone
Your answer
Work Phone
Your answer
Mobile Phone
Your answer
Preferred Phone *
Can we text you? *
Permanent Address
Street Address *
Your answer
City *
Your answer
State/Province *
Your answer
ZIP/Postal Code *
Your answer
Country
Your answer
Current Address (if different from above)
Street
Your answer
City
Your answer
State/Province
Your answer
ZIP/Postal Code
Your answer
Country
Your answer
Are you a U.S Resident? *
If yes, please indicate your Citizenship Status *
Country(s) of Citizenship: *
Your answer
Passport Information
Do you currently have a passport? *
Please note: If you do not currently have a passport it is your responsibility to apply for a passport and to provide this information to Amizade as soon as it becomes available in order to participate on an international program.
Passport Number
If you already have a passport
Your answer
Passport Issuing Country
If you already have a passport
Your answer
Passport Expiration Date
If you already have a passport
Your answer
Date you submitted your application
If you do not have a passport, but have already applied for one
MM
/
DD
/
YYYY
Have you ever been convicted of a crime?
If yes, Please briefly describe the nature of the crime(s), the date and place of conviction, and the legal disposition of the case.
Your answer
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