Application forms for Belmont/Vol State trip - Spring 2012

Application for Short-Term Mission Trip All information is confidential and used only as necessary. All information is required.

Trip: ☐ March 4-10, 2012 ☐ May 6-12, 2012

Personal Information

Name (as it appears on your passport): ________________________________________________________

Address: ________________________________________________________________________________

City: __________________________________________________ ST: ___________ Zip: _______________

Telephone: (home) ____________________ (work) ____________________ (cell) _____________________

Email: __________________________________________________________________________________

Your Occupation: _________________________________________________________________________

Passport Number: ________________________________ Passport Expiration Date: ___________________

Birthdate: ______________________ T-Shirt Size: _____________________________________________

Person to Notify in Case of Emergency

Name: __________________________________________________________________________________

Address: ________________________________________________________________________________

City: ________________________________________________ ST: ___________ Zip: ________________

Telephone: (home) ___________________ (work) ____________________ (cell) ____________________

Email: ________________________________________________________________________________

Medical Information

Health Insurance Company: _____________________________________ Policy No.: __________________

Name of Insured: _________________________________________________________________________

Insurance Company Phone: ________________________________________________________________

Primary Care Physician: _________________________________________ Phone: ___________________

Existing Medical Conditions: ________________________________________________________________

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Medications you take: _____________________________________________________________________

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Known allergies: _________________________________________________________________________

Physical restrictions: ______________________________________________________________________

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Last Tetanus Shot (must be within the last ten years): ____________________________________________

Blood Type: ______________________________________

The Shalom Foundation, PO Box 1354, Franklin, TN 37065 Ph: 615.595.5811 Fax: 615.595.5857

Immunizations Suggested Hepatitis A and B: a two-shot series with the second shot due 6-12 months after first. Tetanus: good for 10 years Typhoid: good for 2 years

Have you been on a mission trip before? Yes / No

If yes, note location and type of trip: ____________________________________________________________

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Church you attend: _________________________________________

List any construction, medical or dental skills/experience you have: ___________________________________

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_________________________________________________________________________________________

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Employer________________________________________________________________________________

Job Title_________________________________________________________________________________

How did you hear about The Shalom Foundation and our missions work?

__________________________________________________________________________________________

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Payment Agreement

Estimated Total Cost of Trip: $1,500

You agree to fulfill your obligation to pay the total cost (minus any scholarship) before departure unless prior arrangements have been made. In event you are unable to make the journey; you still assume the responsibility to pay the amount due in full related to any nonrefundable charges that were incurred on your behalf.

I will comply with the above payment agreement.

(Initial here)

A deposit of $400 (non-refundable) is due to hold your place on the team. Please mail this completed application along with your check (made payable to The Shalom Foundation) to:

The Shalom FoundationPO Box 1354Franklin, TN 37065Or visit: http://theshalomfoundation.donorpages.com/Belmont2012


http://theshalomfoundation.donorpages.com/Belmont2012

Mission Trip Participation Guidelines

Team members that participate in The Shalom Foundation mission journeys are reminded that they are ambassadors of Jesus Christ (2 Cur 5:20). As you go on your mission journey, you represent Jesus Christ, The Shalom Foundation and the United States. This is a tremendous responsibility. For this reason, we ask that each team member seeks to be above reproach in his/her actions and attitudes. Each team member must agree to the following:

Submit to the team leader’s authority in all aspects. Respect the decisions made by the team leader for the benefit of the whole team and the ministry effort.

Do not under any circumstances counsel families or individuals you meet. You could endanger family members or destroy work that’s already being done by the pastors and church/school staff. Refer any situations that may need attention to the team leader only.

Do not take with you a personal agenda when participating in a Foundation mission trip. Although many team members develop strong relationships over the years with families in Guatemala, this is a team trip. Each team should have a unique experience that is especially inclusive of new team members. The focus should remain on the week ahead and what God wants to accomplish newly in this week.

The daily schedule for the trip will NOT be revised, adjusted or changed once the team leaves the US.

We require everyone to abstain from the consumption of alcoholic beverages or any use of tobacco or illegal drugs while on the trip. No exceptions.

Please do not give out or promise money to anyone in the local community or to those to whom we are ministering. Also, do not solicit monies from team members for such a cause without approval of the team leadership.

Do not give out the personal information of a team member to anyone in the host country.

Due to the volatile worldwide political climate, please refrain from discussing political issues or wearing clothing with political messages (including US flags).

Never venture away from the group alone under any circumstances. Always go with a group and always let your team leader know your whereabouts.

Do not offer to fix someone’s home, promise to provide funds or make any promises for support outside the scope of the trip. Team members with good intentions have done this in the past, and then forgotten to follow through. This creates problems between the families and church staff. Please initial this statement symbolizing that you understand the importance of this pledge ___________.

Do not under any circumstances give your address and phone number to nationals. Having your address IS an invitation to come stay at your house at any time, without notice, and for an indefinite period of time! You may be asked to help with visa’s etc.


Be careful in all areas of dress. No shorts or tank tops. Skirts must be below the knee. No shirts with inappropriate logos (US flags, military, etc.). Shirts must be worn at all times.

Be careful as to the language you use. What may be acceptable in our community may not be acceptable in the community you are visiting. Please avoid the use of profanity.

No public display of affection between unmarried couples. Do not pursue dating anyone in the local community or in the host country. Do not pursue dating a fellow team member during the trip.


Mission Trip Participation Guidelines (cont)

If a team member’s behavior is destructive to the team, the ministry or the host community or distracts the team or the leadership from their responsibilities, the Team Leader reserves the right to ask and require the team member to return home. Any additional cost incurred as a result of this action, including but not limited to airfare penalties, changes in airfare prices, taxi rides, etc. will be solely at the team member’s expense.

I have read these statements, understand the guidelines set out above, and agree to behave accordingly.

________________________________Signature and Date

________________________________Printed Name


Photo & Video Release Form

I, ___________________________________________, hereby grant to The Shalom Foundation and its legal representatives and assigns, the irrevocable and unrestricted right to use and publish photographs and video of me, or in which I may be included, for cause awareness, marketing, advertising, editorial trade and any other purpose and in any manner and medium; and to alter the same without restriction. I hereby release The Shalom Foundation, the photographer and the videographer and their legal representatives and assigns from all claims and liability relating to said photographs.

_______________________________Signature

_______________________________ __________________________Print Name Date


Responsibility Release/Waiver of Liability

The undersigned, based upon my application for and in contemplation of assignment for volunteer services by The Shalom Foundation, do hereby state and agree as follows:I acknowledge that by signing this document, I am assuming risks, and agreeing to indemnify, not to sue and release from liability The Shalom Foundation, and its respective officers, agents, employees, directors, volunteers and/or representatives (collectively “Releasees”), and that I am giving up substantial legal rights. This Release is a contract with legal and binding consequences. I have read it carefully before signing, and I understand what it means and what I am agreeing to by signing. In consideration of the acceptance of my application for volunteer services, I hereby freely agree to and make the following representations and agreements. I acknowledge that my volunteer services for The Shalom Foundation may involve inherent dangers and I fully realize the dangers of volunteering my services, and fully assume the risks associated with such provision of such volunteer services. For myself, my heirs, executors, administrators, legal representatives, assignees, and successors in interest I hereby waive, release, discharge, hold harmless, and promise to indemnify and not to sue the Releasees from any and all rights and claims including claims arising from the Releasees’ own negligence, which I have or which may hereafter accrue to me and from any and all damages which may be sustained by me directly or indirectly in connection with, or arising out of, my provision of volunteer services, including travel to or return from such provision of volunteer services.

Dated this the _________ day of __________________________, 20__

Participant Signature: ________

Print Name: ______________

Date: ________


REGULATIONFor the use of the Facilities of the Nazarene Center

Aldea 2-94 Rodriguito Zona 18, Km 8.5 Ruta al AtlánticoTel. 2261-6402 al 4

[email protected]

PURPOSE

To establish internal norms of conduct to be observed and fulfilled by our guests to ensure a proper and pleasant stay in our facilities.

RESERVATIONS

1. The Convention Center provides service to groups of 30 people or more.

2. A group of 300 people or more, with which a contract is signed shall enjoy the exclusive use of the Centre. Smaller groups will share the facilities.

3. Our customer service hours in administrative office are:

8:00 a.m. a 13:00 p.m. And from 14:00 p.m. to 17:00 p.m. from Monday to Friday, Saturday from 8:00 a.m. to

12:00 p.m.

4. Our responsibility with you starts:

At the moment a $100.00 (a hundred dollars) deposit becomes effective or an equivalent in Quetzales (Q800) is deposited to confirm the activity.

Note: if for some reason the activity is no longer hold at the Nazarene Christian Center, the deposit will NOT be refundable.

5. The 50% of the total payment will be done one month ahead of the activity and the other 50% will be paid during the activity.

6. The final payment has to be done with a check from the Ministry or Church responsible of the event on the schedule above.

7. The person responsible of the group will present the program to be developed 15 days ahead of the activity (indicating which areas they will be using and the feeding schedule).

8. The person in charge or host of each group will arrive to the Nazarene Christian Center two hours ahead of the event to be able to give this person the rooms, lounges and keys that will be used during the event.

9. The loss of a key will have a cost of Q25.00, for this reason you should return the complete sets of keys at the end of the event.


mailto:[email protected]

RESPONSIBILITIES OF THE GUEST

a. The Nazarene Christian Convention Center is not responsible for the people that get hurt or suffer an accident due to carelessness or lack of discipline during their stay within our facilities.

It will be the group’s coordinators responsibility.

b. The Nazarene Christian Convention Center administration is not responsible for lost, misplaced or forgotten objects.

c. The guest should take good care of the linen, furniture, bedroom and kitchen utensils.

The total or partial loss of the equipment will motivate the administration to immediately charge its cost at the time of check out.

d. The group leader will organize the hosts or ushers that will be in charge of the behavior and safety of the people that will be participating in their groups (campers as well as staff members).

USE OF THE FACILITIES

1. The entrance or exit of the facilities is permitted from 7:00 a.m. to 22:00 hours.

2. The use of the amplification equipment in the lounges will be allowed from 7:00 a.m. to 22:00 hours and closure of the program.

3. The food schedule service is:

Breakfast 7:00 to 8:00 a.m. Lunch 12:00 to 1:00 p.m. Dinner 6:00 to 7:00 p.m.

4. It is not allowed to move the furniture in each lounge or workshop room to another place.

5. It is prohibited the entrance of pets to the different facilities of the Center.

6. It is not allowed the use of nails or staples on the walls to decorate. (In case you want to decorate, you must use adhesive tape that will not damage the wall paint.)

7. The soccer field and the basketball court will be use exclusively for the use of this ball games respectively.

8. Games of any kind are not allowed to be done in the dormitories or garden areas.

9. Games that involve water are not permitted. LETS TAKE CARE OF THE WATER, WATER IS LIFE.


DORMITORIES

a. For no reason linen, furniture or other equipment in the dormitory should not be moved from its respective dormitory.

b. The use of mattresses is exclusively on the bed and not on the ground.

c. Do not use the sheets or blankets to get dry, nor put them on the floor.

d. The use of recorders or radio in the dorms should be with low volume and no later than 22:00 hours.

e. Trash will be deposited in the containers provided for this purpose.

NORMS OF CONDUCT1. It is prohibited the consumption of alcoholic beverages, cigarettes or other type of drugs

within the premises.

2. It is not permitted to carry firearms, sharp materials or fireworks.

3. The guest should express itself using an appropriate vocabulary.

4. For respect of others guests will not perform unpleasant noises on the premises.

NOTE: Any situation not considered in these regulations should be consulted and resolved by the administration of the Nazarene Christian Center.Thank you for using our services, hope we can serve you again, God bless you.


***** IMPORTANT TRAVEL INSURANCE COVERAGE *****The Shalom Foundation has purchased an insurance policy that includes the following coverage for your trip. This policy does not reimburse the cost of your trip if it is cancelled or interrupted. If you have a pre-existing condition (as described below), this policy will not cover medical expenses unless an additional premium is purchased within 15 days from the date your flight was purchased. If you wish to protect your trip investment, have a pre-existing medical condition that you would like to be covered, or have any questions about this policy, please contact the following agent direct:Lynn [email protected]

All coverages are per person.Trip Interruption -- Return Air Only . . . . . . . . . . . . . . $ 1,000**Trip Delay . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 750(Maximum of $150 per day)Missed Connection . . . . . . . . . . . . . . . . . . . . . . . . . . $ 500Baggage & Personal Effects Loss . . . . . . . . . . . . . . .$ 1,000Baggage Delay . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 100Medical Expense . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ 50,000Emergency Medical Transportation . . . . . . . . . . . . . .$300,000Accidental Death & Dismemberment . . . . . . . . . . . . .$ 10,000

The following non-insurance services are also provided by Travel Guard Assist:Travel Guard Assist . . . . . . . . . . . . . . . . . . . . . . . . . . . .IncludedLiveTravel Assist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .IncludedConcierge Services . . . . . . . . . . . . . . . . . . . . . . . . . . . .Included**Applies if $0 Trip Cost option was selected at time of purchase.

If insurance is purchased within15 days of the “initial Trip payment”:Pre-Existing Medical Condition Exclusion WaivedThis is applicable to all coverages contained in the policy. The Insuredmust be medically able to travel when he/she pays his/her premium. Inthe event that a claim is filed, the Injury or illness must be substantiatedto our Claims Department.Coverage for Financial DefaultThe Financial Default must occur more than 14 days after your effectivedate of coverage.

PRE-EXISTING MEDICAL CONDITION EXCLUSIONAPPLICABLE TO ALL COVERAGESThe Insurer will not pay for loss or expense incurred as the result ofInjury or Sickness of an Insured or Immediate Family Member whichmanifests itself, worsened, became acute, or had symptoms, whichwould prompt a reasonable person to seek diagnosis, care, ortreatment, or request treatment by a physician or treatment hadbeen recommended during the 60 days immediately preceding andincluding the Insured’s coverage effective date, unless the conditionis controlled through the taking of prescription drugs or medicationand remains controlled throughout the 60-day period. A Sicknesshas manifested itself when medical care, treatment, or diagnosishas been given. Applies to the first $25,000 of Trip Cost per person.
