Team Member Agreement

Fields marked with a (*) are mandatory fields.

This application must be submitted with a $500 deposit 60 days prior to trip to secure your spot. The balance of your mission trip fee must be paid in advance to the U.S. office at least 30 days prior to your trip date.

Trip Dates Confirmed (*)
I have confirmed my trip date availability with my team leader or Open Door Haiti staff and understand my airline ticket deposit of $500 is NON-refundable.
Invalid Input
Your First Name (*)

Invalid Input
Your Last Name (*)

Invalid Input
Birthdate (*)

Invalid Input
Gender (*)
MaleFemale
Invalid Input
Address (*)

Invalid Input
Address line 2

Invalid Input
City (*)

Invalid Input
State (*)

Invalid Input
Postal Code (*)

Invalid Input
Email (*)

Invalid Input
Phone Number (*)

Invalid Input
Home Church

Invalid Input
Pastor's Name

Invalid Input
Church Telephone Number

Invalid Input
Trip Date (*)
January 6-11
February 7-9
February 18-25
March 15-20
March 29-April 3
April 19-24
May 31-June 5
June 14-19
July 12-19
July 26-31
August 2-7
September 6-11
October 4-9
October 25-30
November 1-6
December 6-11
Approved Custom

Invalid Input
If you checked 'Approved Custom Dates' - manually enter the dates of your trip AND team leader.

Invalid Input
Your Passport Number (*)

Invalid Input
Passport Issuing Country (*)

Invalid Input
Passport Expiration Date (*)

Invalid Input
Your Weight (for airline purposes) (*)

Invalid Input
Please lIst Your top 3 skills for use on the mission field

Invalid Input
Occupation (*)

Invalid Input
Whom should we contact in case of emergency? (*)

Invalid Input
Relationship to emergency contact (*)

Invalid Input
Address of emergency contact (*)

Invalid Input
Emergency contact phone number (*)

Invalid Input
Emergency contact email (*)

Invalid Input
How did you hear about Open Door Haiti?
Friend
Church
Web Search
Event
Direct Mail or Email
Other

Invalid Input
Please compose a short bio of who you are and why you are going on this trip. This info will be available to your team mates.

Invalid Input
Please upload a personal photo of yourself here. This phot will be available to your trip mates on our iTrips blog page. (*)

Invalid Input

Medical Information/Release

Physician Name (*)

Invalid Input
Physician Phone (*)

Invalid Input
Family Insurance Company (*)

Invalid Input
Policy Number

Invalid Input
Immunizations
Tetanus
Typhoid
Hepatitis A
Hepatitis B

Invalid Input
Other Immunizations

Invalid Input
Are you taking malaria medication? (*)
YesNo
Invalid Input
If so, which medication?

Invalid Input
Blood Type (if known)

Invalid Input
In the past have you suffered any of the following? (Check all that apply)
Asthma Sinusitis Kidney Trouble Heart Trouble Bronchitis Diabetes Dizziness Stomach upset Hay Fever
Invalid Input
Specific Allergy Explanation

Invalid Input
Previous operations or serious illness

Invalid Input
All Current Medications

Invalid Input
Special Diet (be specific)

Invalid Input

Waiver of Liability and Consent

Click here to read the Waiver of Liability and Consent

HEREBY I SIGN THE WAIVER OF LIABLITY AND CONSENT (*)
I agree and sign the waiver
Invalid Input

Code of Conduct

Click here to read the code of conduct

HEREBY I SIGN THE CODE OF CONDUCT AGREEMENT (*)
I agree to the code of conduct
Invalid Input

Security Deposit

I WILL SEND $500 AS MY NON-FEFUNDABLE DEPOSIT FOR THIS TRIP (*)
Yes
Invalid Input

Statement of Faith

Click here to read the statement of faith

OPEN DOOR HAITI STATEMENT OF FAITH (*)
I have read the Open Door Haiti Statement of Faith
Invalid Input
Spell out your name (electronic signature) (*)

Invalid Input
Fill out the 4 characters

Refresh
Invalid Input
Submit this form