North Coast Dominican Republic (10/19/18- 10/22/18)
Join us as we travel and serve. We'll bring donated clothes, buy the local community's food, and distribute the items to two orphanages. Our hope is that by giving basic needs of food, clothes, and love, we'll give these children hope to thrive.
$2000 Includes flight from Miami
Country of Origin:
City, State, Postal Code:
Carefully read the following terms and conditions and indicate your agreement below.
How did you hear about this trip?
Do you have a valid passport:
Name AS IT APPEARS on your Passport:
Date of Birth:
Citizen of what country:
Issued by what country:
Have you ever been convicted of a crime? If so please explain:
List any cross cultural experience you have:
Please explain why you want to go on this trip:
Please describe personal expectations for this trip:
Is your family supportive of your participation:
Please list any questions you have regarding this trip:
What is your strongest character quality and why:
What is your weakest character quality and why:
What do you consider your gifts and why:
Which of the following words would you choose to describe yourself and why: Introvert, Fact Oriented, Extrovert, Perceptive, Intuitive, Feeling, Decisive, Intellectual:
**WORK EXPERIENCE & RELATED SKILLS**
List any languages you speak:
List your profession and any work skills you have:
You may be required to provide a doctor's letter of "clearance" before traveling.
Please list any known medical conditions:
Do you have or have you ever had: Fainting Spells, Heart Problems, Diabetes, Respiratory Problems, Seizures, Eating Disorder, Fear of flying, Car Sickness, Depression, Anxiety, Sleep disorder:
If yes, please describe:
In the past year, please describe your involvement (if any) with: Alcohol, Tobacco, Illegal Drugs, Criminal Activity:
Do you have any chronic illness or allergies:
What is your Blood Type:
Please list any prescription medication you are currently taking:
Have you ever had any psychiatric care/treatment:
Please list any hospitalization history:
How would you describe your health:
**MEDICAL INSURANCE INFORMATION**
Do you have medical insurance:
Medical Insurance Company:
Primary Care Doctor (If HMO):
Doctor Phone Number:
Phone Number of International Contact:
**EMERGENCY CONTACT INFORMATION**
Emergency Contact First and Last Name:
Relationship to you:
Emergency Contact's Address (please include City, State, & Zip):
Emergency Contact's Email Address:
Emergency Contact's Phone Number:
1. By clicking the "I ACCEPT" button below, Participant (i) agrees and consents to the terms of the above Agreement electronically; (ii) agrees that use of electronic sounds, symbols, or processes provided by Participant to establish his or her acceptance or agreement to the terms of the above Agreement constitutes Participant’s electronic signature and signifies Participant’s intent to be bound; (iii) consents to receive an electronic record of the terms of the above Agreement in lieu of a hard or paper copy or version thereof; (iv) acknowledges and demonstrates his or her ability to access electronically this Agreement and their satisfaction of the software and hardware requirements necessary; and (v) confirms and represents that Participant, in fact, has accessed and is able to view, save and print any sample electronic Agreement terms. Participant may click the "Decline" button if he or she does not accept the Agreement terms, but if Participant declines he or she will not be allowed to participate on the Service Trip.:
Subject to Participant’s right to withdraw his or her consent and/or obtain paper copies of the Agreement as provided below, in order to enter into the Agreement Participant must consent to receive in electronic form both: (i) the Agreement terms; and (ii) any other information and communications that Orphan Angels World Wide elects to provide to Participant electronically. Participant agrees that the electronic Agreement will be sufficient as a "writing" under applicable law or regulation. In order to access and retain the electronic Agreement terms and Agreement, Participant must have a computer capable of browsing the internet and access to a printer.:
Participant has the right at any time to withdraw his or her consent to receive the electronic records with respect to the Agreement, and Participant may request and receive a paper copy of the electronic records. If Participant wishes to withdraw such consent, or to request a paper copy of the electronic records, Participant must contact Orphan Angels World Wide by telephone at 904-424-6694 or via email at
If Participant withdraws his or her consent for the electronic Agreement, Orphan Angels World Wide will mail Participant paper copies of the Agreement that Orphan Angels World Wide is required to make after the withdrawal of Participant’s consent; however, the withdrawal of Participant’s consent will not affect the legal validity or enforceability of the electronic Agreement. To the fullest extent allowed by law, Orphan Angels World Wide reserves the right to charge a fee for paper copies of the Agreement in Orphan Angels World Wide’s discretion. Orphan Angels World Wide’s fees for paper copies may change from time to time, and Participant may obtain information about such fees by contacting Orphan Angels World Wide. Orphan Angels World Wide also reserves the right to terminate Participant‘s Agreement in the event that Participant should withdraw his or her consent for the electronic Agreement.:
The Participant has voluntarily chosen to participate in the Service Trip and to be involved in outreach to others by seeking to meet their physical and spiritual needs.The Participant assumes all risk and responsibility for any damage or injury to their property or any personal injury, which the Participant may sustain while involved in the Service Trip, including any related medical costs and expenses. The Participant understands that this short-term Service Trip entails a risk of physical injury and may involve extreme climates, adverse working conditions, hard physical labor and exposure to potentially dangerous areas of the world. The Participant certifies that he or she is in good health and physically able to perform this type of work. Orphan Angels World Wide requires all Participants to be in good physical condition, and may require Participant to obtain a doctor’s exam and prior written approval to participate on the Service Trip. The Participant hereby authorizes Orphan Angels World Wide or its representatives to act for the Participant, in their best judgment and in any emergency requiring medical attention. All medical expenses incurred will be the responsibility of the Participant or the Participant's family. The undersigned certifies that the Participant has no physical condition or mental impairment that would be affected by their participation in the Service Trip. If the Participant is a minor child and the undersigned cannot be reached in an emergency, the undersigned grants permission to any licensed physician, surgeon, clinic, or hospital to secure proper treatment and to order anesthesia, if medically required. Orphan Angels World Wide will arrange for Participant’s accommodations and the Participant understands that Orphan Angels World Wide is not responsible or liable for Participant’s personal effects and property and that Orphan Angels World Wide will not provide lock up or security for any personal property belonging to the Participant during the Service Trip. The Participant further agrees to abide by whatever rules and regulations may be in effect for the accommodations during the Service Trip.
Orphan Angels World Wide requires strict compliance with rules and regulations, including the rules concerning conduct, dress, and conscious lifestyle. These are explained in the Team Agreement, which will be provided to Participant and which Participant agrees to be bound upon acceptance of this Agreement. Failure by the Participant to comply with this Agreement, the Team Agreement or any other rules and procedures related to the Service Trip are grounds for dismissal, without refund or reimbursement. Should a Participant choose to cancel the trip or is dismissed, all application fees and all sponsor funds received by Orphan Angels World Wide will be deemed contributions and are not refundable. Participants may raise funds and receive credit for these funds equal to the price of their trip, including the non-refundable deposit. Each Participant’s trip cost must be paid in full prior to departure. Lack of payment could result in denial of Participant’s attendance on the Service Trip. Extensive training materials will be provided for all approved Participant’s. It is each Participant’s responsibility to complete any assigned tasks and reading in preparation for participation on the Service Trip. The parties to this Agreement are aware of their higher selves and believe in making every effort to live in peace and to resolve disputes with each other in private or within our community. Therefore, the parties agree that any claim or dispute arising from or related to this Agreement shall be settled by Non-Violent Communication mediation and, if mediation is not successful, legally binding arbitration. If the parties cannot agree on a mediator, arbitrator, or location within Broward County, Orphan Angels World Wide shall name three persons or locations and Participant shall choose from those three. Judgment upon an arbitration decision may be entered in any court otherwise having jurisdiction. The parties understand that these methods shall be the sole remedy for any controversy or claim arising out of this agreement and THE PARTIES EXPRESSLY WAIVE THEIR RIGHT TO HAVE CLAIMS ARISING FROM THIS AGREEMENT ADJUDICATED IN A CIVIL COURT, except to enforce an arbitration decision.:
The undersigned, (the individual, including the individual’s parents or legal guardians, if under 18 years of age) listed in Section 1, (hereinafter the “Participant”) in consideration of my participation in the Orphan Angels World Wide Service Trip 2018 Short-Term Service Trip (hereinafter the “Service Trip ”) and the mutual agreements set forth in this Agreement together with other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, the Participant, intending to be legally bound, for myself, my heirs, assigns, executors, and administrators, does hereby waive and release, assume all risks, and agree to indemnify and hold harmless Prosperity Today LLC, d/b/a Orphan Angels World Wide and its integrated auxiliaries and controlled organizations, including their directors, officers, staff, volunteers, or representatives and assigns (hereinafter “Orphan Angels World Wide”) from and against any and all claims for death, personal injuries or property damage, costs, expenses and actions of any kind whatsoever, arising out directly or indirectly out of my participation in the Service Trip, including without limitation liability arising out of negligence or carelessness on the part of Orphan Angels World Wide.
If Participant is under 18:
Parent/Guardian Phone Number:
PLEASE CONFIRM YOUR INTENT BY SELECTING "I ACCEPT" YOU ARE ENTERING INTO A BINDING CONTRACT/AGREEMENT WITH PROSPERITY TODAY LLC (BBA ORPHAN ANGELS WORLD WIDE) BY THE ABOVE MENTIONED TERMS:
*Digital Signature of Participant (Full Name):
Send me a copy of my responses.
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. -
Terms of Service