Trip Member Agreement

Please complete the form below.

Your personal information will be held in confidence by the One 17 International leadership team.

Trip:

First, Middle, & Last Name:

as it appears on your passport if you have one already...

First Name

Last Name

Phone:

(###)

###

####

Email Address:

Address:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Marital Status:

American Airlines Advantage #:

Delta Frequent Flyer #:

TSA #:

Do you have any travel restrictions? Please describe in detail.

Social Security #:

Medical Provider:

Medical Group Number:

Medical Provider Policy Number:

Policy Holder and your relationship to this person:

Emergency Contact Person:

First Name

Last Name

What is your relationship to your emergency contact person?

Emergency Contact Phone Number:

(###)

###

####

Emergency Contact Address:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

List any allergies and/or medical conditions you may have:

List all medication taken on a regular basis:

List all operations/serious injuries (include dates) you have had in the last five years:

Do you have any special dietary restrictions? If yes, please explain:

What type of pain medication may be given to you if necessary?

Emergency Authorization:

I hereby give permission to medical personnel selected by my trip leader or his/her designee (hereafter the Authorized Agent) to order X-rays, routine tests, and treatment for me. In the event of an emergency and neither my primary nor secondary contact can be reached, I hereby give permission to the physician selected by the Authorized Agent to secure proper treatment, hospitalize, order injections and/or anesthesia, and/or authorize surgery for me. I further authorize the release of the above medical information to appropriate medical personnel and/or the health coverage insurance company. In addition, I have, and do hereby, release One 17 International, its employees or agents, and in country contacts from liability associated with participation in a mission trip. I understand that if I do not have medical insurance or workers compensation insurance, I will be responsible for any expenses in the event of a sickness, injury, or loss of wages. I understand that there are risks involved in participating in a mission trip.

Yes, I authorize One 17 International to act on my behalf.

Media Agreement:

I give One 17 International the right to use photos or video of myself from the trip or trip trainings on their website and in other promotional materials.

Yes, I authorize One 17 International to use photos with me in them to promote their work.

Participation Agreement:

I understand that One 17 International reserves the rights to remove me from the trip team roster at any given time if One 17 International's leadership team or my trip leader believes it is in the best interest of the trip team, the individual, or the organization.

Yes, I understand One 17 International reserves the right to remove me from the trip team before or during the trip.

Financial Agreement:

I understand that the $250 trip deposit is non-refundable under all circumstances (involuntary removal from the team roster, personal illness, medical concerns, scheduling conflicts, passport delays, etc). Reimbursement of the non-refundable deposit may be requested but is not guaranteed. A second payment of $600 is due 100 days prior to departure. 100% of your trip cost is due no later than 30 days prior to your trip departure date. The full trip cost will be communicated by a One 17 International representative after airfare is purchased. Airfare is purchased after 100% of your trip team members have turned in at least $850 towards their trip. Trip costs are usually $700 plus the cost of airfare.

Yes, I agree to turn in trip money on time and understand that my flight will not be booked until $850 is turned in by every team member.

T-Shirt Size

Signature:

Today's Date:

YYYY