Mission Trip Registration

Mexico - December 2017

*Final payment due December 10th*
12/27/2017 - 12/30/2017
$300.00
$50.00
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Additional Information

Carefully read the following terms and conditions and indicate your agreement below by checking the boxes. All information on this application will be kept confidential and only disclosed to relevant church staff and volunteers.

*Please note at the end of registration (depending on trip) there will be a non-refundable deposit required, which will guarantee your place on the trip.

*Name as it appears on Passport (for airfare):
*Nickname:
*Date of Birth (mm/dd/yyyy):
*Sex:
*Cell Phone:
Spouse's Name:
Spouses Contact Info:
*Do you have a valid Passport?:
*Expiration Date:
*Country of Citizenship?:
*T-shirt size:
*Church Affiliation?:
If you attend another church, which one?:
*Describe the nature of your present relationship with God:
*Have you been on a mission trip before?:
If so, please list where and when:
*What has drawn you to go on a short-term mission trip?:
*What ministries are you involved in at Pure Heart or your home church?:
If known, what are your spiritual gifts?:
*Are there any spiritual conditions, concerns, or struggles we should know about?:
*Please provide a reference (Pastor, Church Leader, or Discipleship Coach):
*Relationship to reference:
*Phone number and/or email of reference:
*Tell us one of your strongest and also weakest characteristics and why?:
*List any specific talents or skills that you have (ie medical training, musical talent, teaching experience, construction, etc):
*Do you speak any foreign languages? if yes, please list language and proficiency:
*Do you have any physical or mental conditions we should be made aware of? Please list condition(s) and any restrictions:
*Do you have any allergies (indoor/outdoor, food, medical) or special diet restrictions?:
*Are you presently taking any prescribed medications? If yes, please list medication, dosage, and frequency:
*Do you have Health Insurance?:
Insurance Company Name:
Group Policy Holder:
Policy/Group Number:
Claims telephone number:
*Emergency Contact Name:
*Relationship:
*Emergency contact phone number:
By checking the box I understand that as a participant I am required to raise my own support for each trip that Naos, Inc dba Pure Heart Church is sponsoring. Pure Heart will provide material and training, when appropriate, to equip you to raise support. Due to IRS regulations all funds including deposits, donations from supporters, and any personal payments are considered charitable contributions and are non-refundable. I understand that if I cancel my spot on the trip the funds will still go towards the overall mission trip budget and will not be refunded to me or supporters. Any funds raised in excess of the trip cost will be used for the trip or other mission projects.
By checking the box I agree to abide by the directions, rules, regulations, instructions, supervision, direction and authority of Pure Heart Church leadership. I agree to treat our partners, individuals we are serving, and team members with respect and dignity. As a participant, I agree to the time and financial commitment of participating on a short-term mission trip. I understand all that is required of me.
Periodically pictures and video may be taken of me during church events to capture moments in time. I authorize the use of these pictures to be posted on Pure Heart's website and social media pages and/or to be used for promoting upcoming Global Outreach events.
I understand that the events/activities referred to herein have the potential of involving risks of injury, death or damages to me, including, but not limited to sickness, disease, injury, death, criminal activity, political instability, governmental opposition, aggression from indigenous persons or entities and other potential risks to health, welfare, safety and well-being of the participant. I am fully aware of the risks and hazards inherent or possible in said activities/events, and voluntarily assume any and all of such risk of damage, injury, or death, including, but not limited to those risks arising out of the negligence or unreasonable acts or failure to act of Pure Heart Church, and it's affiliates, subsidiaries, divisions, members, leaders, directors, officers, board trustees, employees and agents and any and all other affiliated or related persons or entities (Releasees).
I understand that in consideration of Pure Heart Church allowing the participant to participate in the above activities/events, I, on my own behalf, and on behalf of our personal representatives, assigns, heirs, distributees, guardians, next of kin, and all other affiliated or related persons or entities, (Releasors), hereby irrevocably and unconditionally release, discharge, waive and covenant not to sue Pure Heart Church and its affiliates, subsidiaries, divisions, members, directors, officers, board, trustees, employees, agents, or any other person or entity having a direct or indirect connection to Pure Heart Church (Releasees) for and from any and all claims or causes of action of any nature now or hereafter existing whether known or unknown, including but not limited to all liability to Releasors, on account of any and all damages, injuries, or death as a result of my participation in the above described activities/events, including, but not limited to any claims arising from or out of Releasees own negligence or unreasonable actions or failure to act.
I, the participant, agrees to completely defend, protect, save harmless, and indemnify the Releasees from and against all claims, actions and suits, whether groundless or otherwise, and from and against any and all liabilities, losses, damages, judgments, costs, penalties, charges, attorney's fees and other expenses of every nature and character which Releasees suffer or incur or to which they may be subject or for which it may be liable as a result of the participant's participation in the mission trip and/or any of the events/activities described in this Agreement. If Releasees, in their sole discretion, pay any amounts by reason of any of the matters described above, the participant shall reimburse Releasees within 15 days of receipt of notice of such payments by Releasees. If the participant does not reimburse Releasees within 15 days of such notice , the participant will reimburse Releasees for such payments together with interest thereon at the rate of 10% per annum from the date of the payment of any such amount by the Releasees.
I, as participant, agrees that I bear the sole responsibility for any and all medical care or expenses incurred on behalf of the participant while participating in the events/activities described above, whether arising from or relating to illness, sickness, disease, or injury. The participant acknowledges that Releasees are under no obligation to, and do not provide, any medical insurance for these activities/events.
I, on my own behalf and on behalf of all Releasors, waive and release any potential right to jury trial against Releasees arising out of or from the events/activities described above and also waive and release any potential right to punitive damages arising out of same.
In the event of any claims or disputes arise out of this Agreement, all parties (Releasors and Releasees) agree that such claims or disputes shall solely be resolved by mediation and, if necessary, legally binding arbitration in accordance with the Rules of Procedure for Christian Conciliation of the Institute for Christian Conciliation. All such mediation and arbitration shall take place in Phoenix, Arizona. Judgment upon an arbitration award may be enforced in any Court otherwise having jurisdiction. Releasors and Releasees agree and understand that these dispute resolution methods shall be the sole remedy for any controversy or claim arising out of this Agreement and the Relesees and Releasors expressly waive any rights Releasors or Releasees otherwise might have to file a lawsuit in any civil court for such disputes, except to the extent necessary to enforce any such arbitration decisions. Each party shall bear their/its own costs and attorney's fees associated with such mediation/arbitration decision. We agree to the application of Arizona law to this Agreement. 
The participant warrants and acknowledges that he or she has fully read and understands this Agreement and voluntarily signs (electronically) the same. The participant acknowledges and agrees that the participant is NOT relying upon any oral representations, statements or inducements outside of the terms of this Agreement that might have been made to the participant. 
By entering my full name I recognize that this is equivalent to my legal signature.
*Participant First, Middle, and Last Name: