Mexico 2024 Non-Student Registration

Name

This address will receive a confirmation email

Address

Phone

Emergency Contact

Emergency Contact Phone

Name and Shirt size of all family attending mission

Name, passport numbers and dates of passport application submission for all family attending mission

Medical Information

Medical Insurance Company

Medical Insurance Policy Number

Physician's Name

Physician's Office Number

Dentist's Name

Dentist's Office Number

List any medications all attending mission are allergic to:

List any food all attending mission are allergic to:

List any food restrictions all attending mission have:

List any other allergies all attending mission may have (pollen, insect bites, etc:

Does any one attending mission suffer from, or have ever experienced, or are being treated currently for any of the following: (select all that apply) asthma epilepsy/seizure disorder heart trouble diabetes physical handicap frequently upset stomach other

If other, please explain.

Please list or explain any major illnesses all attending mission have experienced during the last year.

List current medications for all attending mission.

Does anyone attending mission wear: (select all that apply)

glasses contact lenses neither

Date of last tetanus shot for all attending mission.

Are all attending mission vaccinations current?

Yes No

If vaccinations are not current, please explain why:

Should anyone attending mission activities be restricted for any reason, please explain:

Please tell us any other info you think would be important for our doctors and nurses to be aware of:

Drivers

We purchase Mexican Vehicle Insurance for every vehicle we take into Mexico, this information is necessary for that purchase.

Are you willing to drive?

Yes No

If yes, your own vehicle? Yes No

If you are driving, what is your driver's license number?

If you are willing to drive your own vehicle, what is the Make and Model of your vehicle?

What is your VIN?

What is your license plate number?

I will fill out the Mexico 2024 Questionaire

Yes

Signature (type name as signature)

Non-high school children 8th grade and below

If you have any children in 8th grade or below who will be joining you, see below.

If both parents are not traveling to Mexico, a notarized authorization form acknowledging consent to travel to a foreign country is needed.

Yes

Child's name

Child's Birthdate

Child's Passport Number & Date of Passport Application Submission

Payment and Donor information

All non-HS student individuals have two options for payment:
1. Pay full price of $600 per individual
OR
2. Pay $100 down payments per individual AND 10 unique names and addresses per individual registering.

Individual payments

Individual Down Payment

Name

Address

Name

Address

Name

Address

Name

Address

Name

Address

Name

Address

Name

Address

Name

Address

Name

Address

Name

Address

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

Description

March 23-March 30, 2024

This is the registration form for Mexico Outreach 2024, March 23rd-30th. These details are necessary for our planning process and must be completed prior to our first training.

All adults or children under the grade of 8th grade will pay the full amount of $600 OR Pay down payment of $100 AND 10 unique names and addresses per individual registering.

This form must be filled out in its entirety. You can not re-visit a partially filled out form.
NOTE: There is a deposit fee along with this application.

Mexico 2024 Non-Student Registration

Description

Please Fix the Following