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Want to register a GROUP? Call us at 800.881.2170
PARTICIPANT INFORMATION  
   

First Name *

Last Name *

   

Birth Date * (call for child registration)

Gender *

  /    /  
   

Address *

 
   

Address Line 2

 
   

City *

State *

   

Zip *

T-Shirt Size *

   

Phone *

Email *

   


PASSPORT INFO
 
   

Passport Name *

Passport Number *

   


EMERGENCY CONTACT
 
   

Contact Name *

Relationship *

   

Phone *

Email *

   


INSURANCE INFO
 
   

Insurance Company *

Policy Number *

Note: All participants must have health insurance. Please call World Servants if you DO NOT have health insurance.



FOOD & MEDICAL INFO
 
   

Food Allergies & Dietary Restrictions

 
   

Medical Conditions (select all that apply)

Tetanus Shot *

  /  
   

Medications & Other (list medications and other conditions that apply)

Note: Please bring a supply of your regular medication with you (and a written prescription in case of emergency).



WAIVERS & CONSENTS
 
   

Liability Waiver & Release *

 
   
By checking this box, I certify the above information is correct and I HAVE READ THE LIABILITY WAIVER & RELEASE. In an emergency, I give my permission to a licensed physician to hospitalize, anesthetize, or perform surgery as needed.
   
   
   
TRIP INFORMATION

Ariri, Brazil (20-8401)

Friday, June 05, 2020 - Saturday, June 13, 2020

Cost: $1,220/person

Deposit: $150/person

Type: Adult/Family/Church

 

MORE INFORMATION?

Check Out The Trip

Community Information Sheet

 

OTHER AVAILABLE DATES


Ariri, Brazil (20-8402)

$1,220/person | Friday, August 07, 2020


 

 

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