Please print this form, fill it out, attached required documents and mail to the address below.
Trip Destination: __________________ Trip Dates: _________________ Airline FF #: _________
Passport # _____________________________ Expiration Date:_________________________
**Full Legal Name On Passport: _________________________ Date of Birth:_____________
Mailing Address: _____________________________________________________________________
Email Address: _____________________________ Cell Phone #:___________________________
Roommate Preference: ______________________ T-Shirt Size:___________________________
Medical Mission Experience Last 5 Years (Year/Destination; add page if necessary):____
Mission trip area experience/expertise (circle applicable):
Medical Dental Vision Triage Pharmacy
Foreign Language Fluency____________Other__________________________________________
Medical and/or Food Allergies:______________________________________________________
Chronic health conditions/current medications (add page if necessary):_______________
Physical and/or Dietary Limitations:________________________________________________________
List two Emergency Contacts in USA (Name, Relationship, Address, Phone, Email). The team physician for the trip is designated for medical care decisions unless you want to decline his/her care. If you want to decline, you must send an email to team leader and designate another person on the trip.
** All trip applicants must attach a copy of their current passport
** Medical professionals must attach copy of current license
PO Box 54786
Hurst, TX 76054
Release of Liability
Trip Destination: __________________ Trip Date: __________________
The undersigned acknowledges and states the following: I have chosen to travel and work as a volunteer
for Global Hands of Healing, Inc. (GHoH), a 501 (3) c Texas Corporation and engage in the activities
related to being a volunteer for a healthcare mission team. Limited to Destination & Dates noted above.
I understand that this work could entail a risk of physical injury. I certify that I will not do any work that I
am physically unable to perform.
I understand I am engaging in this trip at my own risk. I assume all risk & responsibility for any damage or
injury to my property or any personal injury, which I may sustain while involved in this project, and related
medical costs and expenses if not compensated for by insurance.
This Release discharges GHoH from any liability or claim that I, the undersigned, may have against
GHoH with respect to bodily injury, personal injury, illness, death, or property damage that may result
from my participation on the GHoH trip.
I grant unto GHoH all right, title, and interest in any and all photographic images, video or audio
recordings that are made GHoH during my work with GHoH.
This Release is intended to be broad and inclusive as permitted by the laws of the State of Texas in the
USA; and shall be governed by and interpreted in accordance with the laws of the State of Texas.
Volunteer Signature Volunteer Printed Name
PO Box 54786
Hurst, TX 76054