TRIP REGISTRATION FORM

REGISTRATION PROCESS

This form is to be completed and returned to IMPAC 2 months prior to each mission trip.

Please fill out all 6 sections of this registration form:*

A. Registration Information
B. Policy Agreement and Signature
C. Medical Information
D. Medical and Liability Release
E. Official Agreement and Signature
F. Notarization Permission Form (If Necessary)

(please check each box when completed)

A. REGISTRATION INFORMATION

Trip Date And Location: August 7-14, 2021 / Dominican Republic

T Shirt Size*

Name*

First Middle Last Preferd Nickname

Address*

Street Address City State / Province / Region ZIP / Postal Code

Telephone: Cell*

Home

Work

Email*

Gender*

Female
Male

Age*

Date of Birth*

Citizen of*

Birthplace*

Occupation*

Company*

Title*

Description*

Church*

Senior Pastor’s Name*

Church Phone Number*

Church Website*

Address*

Street Address City State / Province / Region ZIP / Postal Code

B. POLICY AGREEMENT AND SIGNATURE

As a representative of Jesus Christ, my home country, and IMPAC, I will behave at all times in a manner that brings glory and honor to these institutions. I will respect and follow the decisions of IMPAC. I am aware that my every word and action is being watched during the entire missions trip experience. Therefore, I agree to act and talk in a manner that glorifies the name of Jesus Christ. I want everything I do or say to draw people to Jesus. I will be spiritually, physically, and mentally prepared for a mission trip that will stretch me and mold me in ways that I can only imagine. As a guest in the country I am visiting, I will respect and follow the traditions of the local people and nationals. For example: if the way I dress offends them, I will change. I will go to learn from the people I am visiting. I will not criticize the culture, efficiency, work habits, food, traditions and such, with which I come in contact. I will not go to judge, but to learn, and to share the person of Jesus through my words, actions, and deeds. I agree to have a servant attitude at all times. When I am doing a task or ministry I don’t particularly care for, I will try my best and be a witness in this activity. I will use words that encourage and build up my team members and the nationals at all times. This means I will refrain from gossip or words that bring dissention and take focus away from the goals of the trip. I will have a positive attitude at all times. Every trip has its challenges and unforeseen circumstances. People could get sick, items lost, and plans changed. I realize that there are times I will need to adjust my expectations and plans and look at challenges as opportunities to be a witness for Jesus Christ. I will work with all members of the team. I will refrain from pursuing romantic relationships during the trip. If my spouse or significant other is on the trip with me, I will make every effort to spend time with each person of the group and interact with all team members. I realize that sleeping accommodations most likely will not allow me to stay in the same room as my spouse. Men will be in rooms with men and women with women. For trips with accommodation a hotel, rooms will have 3-4 people per room. I will attend all team meetings and fulfill the responsibilities I have agreed to before, during, and after the trip. If I am not able to attend a meeting I will be in contact with IMPAC to discover what I have missed. I will abstain from using, consuming, or possessing alcohol, tobacco products, and illegal drugs while on the trip. I will not steal or commit illegal act while on the trip. I also will not talk negatively about my country’s politics or the host country’s politics during the trip. If in the future I desire to return on another missions trip to the country I’m now scheduling to visit with IMPAC, and wish to visit any connections or ministry locations from this trip, I must do so through IMPAC or receive IMPAC’s written permission to do so. This will enable the overall vision and plans for the ministry as agreed upon through IMPAC’s connections in the country, to continue. I will follow the travel, supply, clothing, financial, and medical guidelines set forth and explained to me prior to the trip. I am responsible for knowing and following everything explained at the team meetings. I will follow all import and export laws. I will not attempt to bring any item or good into the host country or back into my country that is banned. If I break any of the rules listed above, at the discretion of an IMPAC representative and in conjunction with my group leader, my missions trip can be terminated and I can be sent home at my own expense. I realize that to attend this trip and represent Jesus Christ on the mission field is a privilege and if I abuse that privilege this constitutes the right for my trip to end prematurely.

Signature*

Date*

C. MEDICAL AGREEMENT

(Please fill out the top section to the best of your ability.)

Date of last Tetanus Shot*

Blood type*

Immunizations:

MMR (Measles, Mumps, Rubella)*

Yes
No

Typhoid*

Yes
No

Hepatitis A*

Yes
No

Travel insurance premium included in personal expenses cost paid by team member.

Name of Travel Insurance Company (Arranged by IMPAC)*

Phone*

Address*

Street Address City State / Province / Region ZIP / Postal Code

Policy*

Policy # Group #

Name of Personal Insurance Company*

Phone*

Address*

Street Address City State / Province / Region ZIP / Postal Code

Policy*

Policy # Group #

Please list any medical or first aid training you may have:*

Licensed medical personnel expecting to practice medicine overseas must mail photocopies of credentials to IMPAC.

If you are presently being treated for an injury, sickness, are under a doctor’s care, or have any mobility limitations, please explain:*

Please list any food allergies or dietary restrictions:*

Please list specific known allergies*

(medicine, environmental, insect, etc.):

D. MEDICAL AND LIABILITY RELEASE

Matthew 18:15-20 and 1 Corinthians 6:1-8 instruct us to live at peace and to resolve disputes in private or within the Christian Church. I realize that the limited charitable resources of IMPAC should not have to be dissipated on litigation. Therefore, I expressly waive my right to file a lawsuit in any civil court or other secular setting against IMPAC, its representatives and entities, other organizations, and all individuals involved with IMPAC’s mission trips. I hereby release IMPAC and all organizations involved with IMPAC’s mission trips from any and all legal liability. I hereby waive all my rights to any legal liability on the part of IMPAC or any other individuals or organizations involved, from which liability may result from sickness, injury, or death that may occur on or related to IMPAC trips. I fully realize that there are hazards, and I am fully assuming these risks, including but not limited to: hazardous traffic, poor roads, food, allergies, dangers resulting from military or political problems, storms or hurricanes, sickness, injury, and disease. I specifically release IMPAC and its representatives from any claim of negligence in their duties as leaders or otherwise on IMPAC trips. In the event that I attempt to make a claim in violation of my release and waiver as herein indicated, I hereby agree to, and shall pay, all legal fees and costs incurred by IMPAC and other individuals and organizations involved. I hereby acknowledge that representatives of IMPAC will be taking pictures and videos throughout the trips. I agree by signing this form to allow my image to be used solely by IMPAC in promoting future mission trips. I may decline to have my image included by sending an email to info@myimpac.org or a written letter to IMPAC, stating that I decline to have my picture and video image included in future promotional materials. In the event that it should become necessary, whether in an emergency or otherwise, I authorize IMPAC and its leaders, serving as its agents to arrange for any and all treatment including but not limited to: x-ray examinations, anesthesia, dental, medical, surgical, and/or treatment and/or hospital care for said participant on behalf of participant; and in such event, said participant agrees to pay for all costs, charges, fees, and expenses and travel and/or emergency expenses incurred as a result of treatment. The undersigned represents that the participant suffers from no disease or injury and has no other requirements for supervision, medication, or care other than those listed previously on this form. I assume the full responsibility for any and all medical bills and early evacuation/transportation costs incurred related to mission strip that are not already covered or paid for. I have read and am in full agreement with this release and waiver and policy agreement, and fully understand that I am waiving any rights I may have to litigate and sue. I accept full responsibility for visiting a doctor prior to the trip, all insurance, transportation to/from the host country, and all medical costs. I authorize IMPAC and its agents to make medical decisions on my behalf and agree to read and abide by all IMPAC rules as outlined in the Policy Agreement.

E. OFFICIAL AGREEMENT AND REQUIRED SIGNATURE

Name*

First Last

(applicant name)

Signature*

Date*

Are you younger than 18 years old?*

Yes
No

F. NOTARIZATION PERMISSION FORM

THIS SECTION SHOULD BE PRINTED AND MAILED TO IMPAC:
PO Box 754, Danbury CT 06813

ONLY FOR TRAVELERS UNDER 18 YEARS OF AGE.

Submit this notarized this consent form to IMPAC prior to the mission trip. Failure to do so will most likely result in being denied boarding of the intended flight or entry into the intended country. The original copy of this form will be provided at the airport or to an immigration agent upon request.

We, the undersigned,

and

do hereby grant full permission for our son/daughter

whose birthday is

permission to travel with

on the dates of

SIGNATURE OF FATHER OR GUARDIAN:

Date

SIGNATURE OF MOTHER OR GUARDIAN:

Date

Address

Street Address City State ZIP Code

Phone

THIS SECTION SHOULD BE PRINTED, NOTARIZED AND MAILED TO IMPAC:

P.O. Box 754, Danbury CT 06813.

TO BE COMPLETED ONLY BY TRAVELERS UNDER 18 YEARS OF AGE.

Failure to submit this notarized consent form to IMPAC prior to the mission trip will most likely result in being denied boarding of the intended flight or entry into the intended country. The original copy of this form will be provided at the airport or to an immigration agent upon request.

Subscribed and Sworn to before me this

Date

NOTARY’S PUBLIC SIGNATURE

SEAL

Notary Public In and For the County Of:

And the State of:

Print

REGISTRATION PROCESS

A. REGISTRATION INFORMATION

Trip Date And Location: August 7-14, 2021 / Dominican Republic

B. POLICY AGREEMENT AND SIGNATURE

C. MEDICAL AGREEMENT

Immunizations:

Travel insurance premium included in personal expenses cost paid by team member.

D. MEDICAL AND LIABILITY RELEASE

E. OFFICIAL AGREEMENT AND REQUIRED SIGNATURE

F. NOTARIZATION PERMISSION FORM

THIS SECTION SHOULD BE PRINTED, NOTARIZED AND MAILED TO IMPAC:

Quick Links

Team Documents

TRIP REGISTRATION FORM