Northwest Haiti Christian Mission

Click here for printable application

* = Required fields

* Anticipated Trip Date:

* Departure City:

* Name (as it appears on your passport):

Passport number: Expiration date:

Date of Birth: (Year)

* Address:

* City: State: Zip:

* Home Phone:

Cell Phone:

Work Phone:

* Email address:

* Gender: Male Female

Marital status:

Home church:

Occupation:

Team Leader:

* Shirt size (S-XXXL):

* Emergency Contact:

Relation:

* Emergency Contact Phone number:

What is the general state of your health?

Do you have health related problems in the following areas?

Blood pressure
Heart
Lungs
Diabetes

   If your Doctor requires you to take any medication on a regular basis,
    please explain what the medication is and why you are taking it:

Recent immunizations:

What is the main reason you wish to go on this trip?

What is the main thing you wish to accomplish on this trip?

Please list some of your skills/gifts that you would like to use in Haiti:

I, , do hereby certify that I am willing, physically fit and sufficiently prepared to travel with and participate in a work project with the Northwest Haiti Christian Mission, in the country of Haiti.
Trip sponsors have my permission to take me to a doctor for medical treatment, hospitalization, or emergency surgery if the need should arise. Should it be necessary for me to return home prematurely (due to medical reasons or disciplinary action), I will assume total responsibility for any additional costs incurred.
I have read and agree to abide by the regulations and information included on the Rules web page.
Your signature:    Date:
Parent/Guardian signature:    Date:
(If under 18)
Recommending minister:    Date:

(Please include title and name of congregation. A requirement for first time travelers is to obtain a recommendation from a minister from your congregation. Please include their name and the date they gave you permission to submit this form.)
Note: The mission DOES NOT make any money on group trips to Haiti. If you decide not to go, you must let us know a month before your departure or you will be responsible for any and all penalties with airline tickets. Tickets are good up to one year if you decide not to go!

The cost of the trip ranges from $1,400-$1,700, depending upon airfare. It is important that you send in this application Ninety (90) days before your trip date, along with a $500 deposit.

(Note: To sumbit another application, click your browser's "Back" button to return to this form. You can then change the information relevant to each person without having to retype similar family information.)