HOUSE BUILD PARTICIPATION FORM

TRIP INFO
Trip Date *
Trip Date
REGISTRANT INFO
Name *
Name
Address *
Address
Phone *
Phone
Date of Birth *
Date of Birth
(If none, please put N/A)
RELEASE OF LIABILITY/CONSENT
DO YOU AGREE TO THE ABOVE STATEMENT?
DO YOU AGREE TO THE ABOVE STATEMENT?
DO YOU AGREE TO THE ABOVE STATEMENT?
DO YOU AGREE TO THE ABOVE STATEMENT?
DO YOU AGREE TO THE ABOVE STATEMENT?
Date *
Date
MEDICAL RELEASE FORM
Registrant Name *
Registrant Name
Doctor's Phone *
Doctor's Phone
(If none, please put N/A)
(If none, please put N/A)
(If none, please put N/A)
Medical Problems:
EMERGENCY PHONE NUMBERS (Please list 2 including name and relationship to applicant)
Name *
Name
Phone *
Phone
Name *
Name
Phone *
Phone
CONSENT FOR EMERGENCY MEDICAL TREATMENT
Please Note: It is understood that every attempt will be made to notify the volunteer’s emergency support system before treatment is given.
DO YOU AGREE TO THE ABOVE STATEMENT?
PARENTS/LEGAL GUARDIANS (For participants under 18)
(If self, type "n/a")
(If self, type "n/a")
Date *
Date
International Volunteer Insurance Coverage
Coverage is available for as little as $3.30 per person, per day and will normally cover: • Medical emergencies • Emergency extraction • Personal liability • Lost or damaged luggage • Travel disruptions such as flight cancellations • Loss of valuable items • Other unforeseen events • For more information on coverage ask your Baja Bound representation.
I would like to receive Baja Bound's monthly newsletter, to the email address I entered above, to hear about their latest trips, future aspirations, and what I've helped them accomplish. *
You are able to opt out of our infrequent newsletters at any time.