For Accommodations: *

Single Occupancy

Double Occupancy

Home Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Cell Phone *

(###)

###

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Date of Birth *

MM

DD

YYYY

Passport Date of Expiration *

MM

DD

YYYY

Contact's cell phone: *

(###)

###

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Passport Options

My passport is currently getting renewed

I will email a copy of my passport to Carol Dublin at a later date

Waiver of Liability and Emergency Authorization *

I am participating in an Outreach Foundation mission trip of my own free will and understand that I should not participate unless I am physically and medically able. In consideration of The Outreach Foundation allowing me to participate, I assume full and complete responsibility for any injury, accident or illness that may occur while I am traveling to or from my home city and during my travel with The Outreach Foundation. I give any licensed, practicing physician or hospital full authority to provide emergency medical treatment for me in the event such treatment is needed or necessary and I am not able to make such a decision. I also hereby give my permission for a licensed, practicing physician to administer whatever medical treatment he/she may deem necessary for me in the event of any medical emergency affecting me. I understand that any expenses that are incurred by me due to accident or illness are my responsibility and not the responsibility of The Outreach Foundation. I also am aware of and assume all risks associated with participating in this mission trip. I, for myself and my heirs and executors, hereby waive, release and forever discharge The Outreach Foundation, its trustees and staff, its agents, representatives, successors and assigns, and all other persons associated with the mission trip, for any and all liabilities, claims, actions, damages, costs and/or expenses that I may have against them arising out of or in any way connected with my participation in this mission trip. I understand that this waiver includes any claims, whether caused by negligence, the action or inaction of any of the above parties, or otherwise.

I understand and agree to the waiver

By typing my name below, I acknowledge that as my "signature" for this waiver

Waiver of Liability and Emergency Authorization Signature *

First Name

Last Name

Payment Acknowledgement *

The trip costs may be paid online at https://www.theoutreachfoundation.org/give-page. You may also pay by check mailed to The Outreach Foundation, 381 Riverside Drive, Suite 465, Franklin, TN 37064. The $150 trip deposit per person is due now. One half of the remaining trip expense will be due 60 days from the start date of the trip with the balance due 30 days from the start date of the trip. We will contact regarding amounts and specific deadlines for payments and to confirm receipt of your application.

I have read the above payment structure and deposit notice

I am paying my deposit online

I am mailing a check for my deposit