About Us
Staff
Lodging
Gallery
Contact
News
Host a Build
Interest Form
Group Leader Agreement
House Build Participants
House Project Payments
Specific Build Fundraisers
Store
Broken Rib Coffee
Donate Now
About Us
Staff
Lodging
Gallery
Contact
News
Host a Build
Interest Form
Group Leader Agreement
House Build Participants
House Project Payments
Specific Build Fundraisers
Store
Broken Rib Coffee
Donate Now
Baja Bound
Participation Form
Event Name
*
Event Date
Name
*
First Name
Last Name
Phone
(###)
###
####
Date of Birth
*
MM
DD
YYYY
Home Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email
*
Do you have a valid passport?
*
Yes
No
Nationality
*
Passport number & expiration date
*
Have you participated in a home building project before?
Yes
No
Do you speak Spanish?
*
Yes
No
If yes, what is your verbal ability?
Beginner
Understand some
Able to respond sometimes
Advanced
Fluent
Please list all relatives on this trip
*
Full Name and relationship to you (if none, please put N/A)
Insurance Carrier
*
Policy Number
*
Group Number
*
Doctor's Name
*
Doctor's Phone
Medical History
If none, please put N/A
Allergies
Please list ALL medication taken regularly
both prescription & non-prescription (if none, please put N/A)
Medical Problems
Diabetes
Fainting Spells
Epilepsy
Hepatitis
High Blood Pressure
Asthma
Blood Clotting Disorder
Heart Defect/Disease
Other
If other, please explain
1st Emergency Contact: Name, relationship & phone
*
2nd Emergency Contact: Name, relationship & phone
*
Monthly Newsletter
I would like to receive Baja Bound's monthly newsletter to hear their latest news.
Yes
No
Thank you!
