Application for Trips in 10/2012 and 4/2013

APPLICATION FOR WAYS MISSION TRIP TO HAITI

Sponsored by Workdays for Adults and Youth in Service and Union Church

Name ___________________________________Phone _____________ Date of Birth ___________

      (print name exactly as it  appears on your passport)

[Name you would like to be called _________________________________]

 Phone #_________________________
 E-mail (yours or a friends - for trip info.) _______________________

Mailing Address ______________________________________ 

Town _________________________ State _____ Zip ____________

Emergency Medical Contact _____________________Relationship____________
Phone _______________

                                    (Someone not traveling with you.)

Insurance Beneficiary ________________________________      Phone _______________

                                    (Beneficiary for missionary accident insurance.)

Male __  Female __                                       Age:      _____ (Minimum age is 18 years.)   

Home Church _______________________________ ___________

Church with whom you're traveling if different than home church _______________________________
___________________________________

Reference - a leader or clergy person in your faith community whom we can contact

_____________________________________________________________________________

                (   name                                   `                                                               name of congregation                                                               phone #  )

Dates of planned trip in which you are hoping to travel:
             Oct. 27-Nov. 3/ ’12 chicken farm and pediatric therapists educational consultants   ___ 
             April 6–13/ ’13 medical team  and nursing and educational consultants  ___

Construction team ________

Medical team _________

Children’s activities___(1 day sessions of Children’s Bible School stories, crafts, songs, & other activities)

Other (specify)_____________________________

FLIGHTS (Airfare and transportation to the airport is not included in your cost):

The flight cost from Boston / NYC to Port au Prince is expected to be about $600.

 (We are glad to book your tickets when the minimum number of participants is met.)

                                    PERSONAL MEDICAL INFORMATION                                                     

List any physical limitations      ________________________________________________________ 

Most recent tetanus shot date (recommendation to be within the last 5 years): _________

Health Insurance Information                                

Please Bring Card to the Worksite 

POLICY PROVIDER______________________                         #_________________________

EFFECTIVE DATES__________________                                 

FOR MORE INFORMATION PLEASE CONTACT:

The Rev. Shantia Wright-Gray        Coordinator for local and global Workdays for Adults and Youth in Service (WAYS)  shantiawg@gmail.com   508-450-2001, PO Box 7028, Ocean Park ME 04063

CONSTRUCTION - WORK EXPERIENCE RATING :

Participants can have work experience ranging from none to professional.  We will try to take this information into account as we assign you to a project, so please give an accurate assessment of your experience.  (You might be asked to bring portable tools to the workcamp that will enable you to use this experience.)

            Use the following number guide to indicate your experience level in each category below.  If you are under 18 years  of age and mark yourself as having Medium Experience (level  3) or Advanced Experience (level 4) in any area, you must have your parents sign in the box at bottom of the application.

0.-No Experience                     1.-Low Experience                                                      2.-Medium Experience           

            3.-Advanced Experience                                 4.-Professional Experience (Adults Only)

CONSTRUCTION WORKERS (to aid in assigning you to a project that will be suitable for you and rewarding): Please enter the number which best reflects your level of experience in the following categories. Indicate only one number per category.

 __ Painting             __ Carpentry                  __ Drywall                     __Masonry 

                         __ Electrical           __ Concrete Works         __Heating/Cooling               __ Roofing

 __ Siding              __ Plumbing    

Operating equipment:

Power Tools, Heavy Equip (i.e. bulldozer, front end loader, etc) _____________________________________

Trade licenses: ________________________________                                                 In what states?________________           

MEDICAL TRAINING: (what area)_____________________________________________

licensed?______  In what state?_________ 

CHILDREN’S ACTIVITIES -1/day VBS type experiences

Willing worker __________ 

Special Skills

     (crafts, church school teacher, music/singing, drama etc.) please specify __________________________

OTHER SKILLS:

   Licensed Therapist _________                                Social Service training _______

   what professional training/certification?    ___________________________________

  Farming skills - please describe ____________________________________________ 

  Other _________________________________________________________________________

PAYMENT ENCLOSED:  Initial deposit:                                                                                            $200.00                                                          (Deposit is Non-Refundable once tickets are booked) 

                                              Second Payment: due  3  months before trip                                         $500.00

                                                      

                Balance due: 2 months before trip                                                           $600.00

               TOTAL                                                                                      $1300.00 (not including airfare)

           

1. MAKE CHECKS PAYABLE TO -   “Union Church” (and mark the memo line with “Haiti Trip”)

2. MAIL THIS FORM AND YOUR INITIAL DEPOSIT TO:

Shantia Wright-Gray

            PO Box 7028

            Ocean Park, ME 04063

3. SECOND and FINAL PAYMENTS: should also be sent directly to Shantia