TRIP DETAILS

RWANDA OVERVIEW
TRIP DETAILS
RWANDA FAQ

OUR WORK IN RWANDA

TRAVEL DATES

TBD

AGES GROUP

All Ages

Trip Cost

$2,200

Trip Durantion

10Nights / 9 Days

Rwanda Trip Application Form

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Full name as it appears in your passport *

First

Middle

Last

Phone *

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Passport # *

Expiration Date *

Citizenship Country *

Date Of Birth (dd/mm/yyyy) *

Male/Female *

Male
Female

Marital Status

Married
Single
Widowed
Divorced

If married, Write Spouse's name

What's the name of the church you attend?

REFERENCES

REFERENCE 1 - Name and Lastname *

Please list two references, other than family, who can be contacted on your behalf.

REFERENCE 1 - Phone *

REFERENCE 1 - Relationship *

REFERENCE 1 - Email *

REFERENCE 2 - Name and Lastname *

Please list two references, other than family, who can be contacted on your behalf.

REFERENCE 2 - Phone *

REFERENCE 2 - Relationship *

REFERENCE 2 - Email *

GENERAL HEALTH

MEDICAL HISTORY

Have you ever had any of the following?

Asthma
Blood Disorder
Cancer
Diabetes
Fainting Spells
Heart Disease
Hepatitis
High Blood Pressure
Kidney Disease
Lung Disease
Migraine Headache
Recurrent Infections
Rheumatic Fever
Seizure

Please choose as many as you need to indicate.

Other, please explain

Medications

List all medications (both prescriptions and over-the-counter) you are currently taking ( name and dosage).

Allergies

Specify any allergies to medications, foods, insects, etc and describe reactions.

Diet

Explain any special dietary needs

Additional medical information your team leader should be aware of

MEDICAL INSURANCE INFORMATION

Health Insurance Company Name *

Group # *

Subscriber Name *

Policy # *

Primary Doctor's name *

Phone *

Date / Time

SPIRITUAL JOURNEY

Please Share who Jesus Christ is to you, how does He impact your life? *

In what ways have you recently served/volunteered Iwith AHEC or other ministries *

MISSION EXPERIENCE

Share your previous mission experience, including sending mission organizations, ministry, location, tips and duration. *

If you have never been on a mission trip, type: None.

How do you hope this short-term ministry experience will affect you life? *

What are you known gifts and talents? *

LEGAL WAIVER SIGNATURE:

m aware that all positions are voluntary, without financial remuneration. I agree to abide by all present and subsequent issued rules of Apple Of His Eye Charity . I clearly understand that raising all expenses, including travel to and from the designated location, will be my responsibility. I further agree that AHEC has the right to discontinue my ministry through AHEC at any time at its sole discretion. I recognize that participation on a trip of this nature may be hazardous or dangerous. Therefore, I am, for myself, my heirs, executor and/or administrator, releasing and forever discharging AHEC and all its officers, agents, servants and employees, acting officially or otherwise, from any and all reason of injury, damage (including property damage to any of my belongings), loss or death which may occur from any cause including, but not limited to, any accident and/or occurrence while participating individually or with others while with this mission agency and/or on this mission trip. Furthermore, I realize all contributions to AHEC are tax-deductible. Contributions are non refundable in the event that the applicant chooses not to participate in the program. The financial disbursement of these funds is at the discretion of AHEC. Funds given in excess of the individual’s program cost cannot be returned but will be used to further the ministries of AHEC. I give Apple Of His Eye Charity the right to use my picture/video, voice and/or testimony in any form of promotional advertising materials. The information I have given Apple Of His Eye Charity is accurate and true to the best of my knowledge. My signature (and signature of my parent/legal guardian if applicant is a minor) signifies authorization. *

Clear Signature

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