Liability Release Form
Basic Facts
Who? ANY individual interested in supporting relief efforts in Haiti
What? Construction project(s), children’s programs, various skills training workshops, physical therapy consults, possible mobile medical clinic(s) and whatever else is needed!
Where? Haiti (primarily Jacmel, potentially St. Roc, Seguin and/or Marbial)
When? January 8-15, 2010
How much? $450 + airfare (see budget and payment schedule below)
Frequently Asked Questions
How can I pay for the trip?
If you are not able to afford the cost of your trip, the sponsor letter included in this package is a great way to help get financial support. All contributions made to help support the team are tax deductible as long the funds are solicited according to the guidelines in that letter. Contributions for your own trip are also deductible. Any extra funds will be used specifically for relief efforts in Haiti.
Partial trip scholarships are also available to those who qualify. Please contact Kathy.nomides@ for information.
Where will we be staying?
Accommodations will vary depending on your assigned work site.
Do I need a passport?
Yes.
What immunizations or medicine will I need?
Typhoid, Hepatitis A and Malaria prophylaxis (malarone, doxycycline or meflaquine) are recommended
Are there any age restrictions?
Anyone under 18 must be accompanied by an adult.
How do I sign-up?
To be considered for the team, return the completed registration and liability release forms to Jennifer or Kathy Nomides. Once your application is accepted a non-refundable deposit of $200 is due and you will receive your orientation package.
What about training?
We will be holding three mandatory training sessions. For those out of the area, training may be conducted through teleconferences and email.
Can I book my own airfare?
Absolutely. Just make sure you are on these flights out of and into Miami.
Saturday, January 8 - American Airlines Flight 1291 departing Miami at 10:05am, arriving PAP at 12:15pm
Saturday, January 15 - American Airlines Flight 816 departing PAP at 10:50 am, arriving Miami at 1:00 pm
Estimated Budget and Payment Schedule
(for those NOT purchasing their own plane ticket)
|Activity | US Dollars | |
|Individual Costs | |
|Registration fee | $ 20.00 | |
|(includes training material) | | |
|Round Trip Airfare from PHL* | $ 832.00 | |
|Trip insurance (medical only) | $ 30.00 | |
|Food and lodging | $ 300.00 | |
|In-country transportation | $ 100.00 | |
|TOTAL | $ $1282.00 | |
| | | |
|Potential Personal Expenses | | |
|immunizations | | |
|passport | | |
|Schedule of Payments |
| | |Due Date |
|deposit | $ 200.00 |upon registration |
|first payment | $ 500.00 |11/15/10 |
|second payment | $ 500.00 |11/30/10 |
|third payment | $ 82.00 |12/31/10 |
|TOTAL | $ $1282.00 | |
* Based on approximate cost of round trip airfare from PHL to PAP. For individuals booking their own airfare the cost of the trip will be $450, the total of which is due on 12/31/10. Note, we are also able to make the travel arrangements for those flying out of other cities within the US and will adjust the price of airfare accordingly.
Self Evaluation for a Short Term Mission Trip
1. Is God calling me to this area of ministry?
Pray about it.
2. Do I have a servant’s heart?
Am I willing to ask “How can I help?” instead of “Let me show you how”.
3. Am I willing to be a team player?
Can I work with others towards a common goal? Can I accept authority?
4. Am I flexible?
How do I handle it when things don’t go as planned? Can I adapt and learn to “go with the flow?”
5. Am I willing to embrace another culture?
Can I adjust my behavior and dress accordingly?
6. Can I accept being a guest in someone’s home under conditions that may be more primitive than what I am used to?
7. Will I be able to survive on a diet that may be very different from what I am accustomed to?
Where you lead me I will follow; what you feed me I will swallow.
8. How will I handle the financial commitment?
Will I need to find sponsors? Do I want to be part of the fund raisers?
9. Can I afford to take time away from my family and/or my job?
If you feel comfortable about your answers to these questions and are ready to sign-up, turn in the following registration form to Kathy or Jennifer Nomides along with the signed liability release. If you still have some questions you need to discuss before making a commitment, please contact us and we will be happy to give you some more insights that you may need to help you prayerfully consider this commitment. Once your application has been accepted a $200 non-refundable deposit will be due and you will receive your orientation package.
Registration Form
General Information:
Print your name as it appears on your passport.
First ____________________ Middle _________________ Last ______________________
Preferred Name__________________________ Passport No.________________________
Mailing Address _____________________________
_____________________________
City________________________ State_______ Zip___________
Telephone______________________ Email ________________________________
Occupation______________________ Date of Birth__________ Gender ___M ___F
Emergency contact:
Name/relationship:______________________________________
Phone: ________________ E-mail: ________________________
Background Information:
Hobbies/Interests________________________________________________________________
List any special skills you can bring to the team such as photography, teaching, writing, language skills, construction, medical, etc.
______________________________________________________________________________
List any previous international travel experience_______________________________________
______________________________________________________________________________
List any medications you are taking and for what condition______________________________
______________________________________________________________________________
List any special dietary requirements________________________________________________
______________________________________________________________________________
Why I want to go (feel free to continue writing on the back of the form)____________________
______________________________________________________________________________
Liability Release Form
Short Term Mission Trip to Haiti
In consideration for being accepted by Branch Community Church for participation in the short term mission trip to Haiti, we (I), being 18 years of age or older, do for our selves (myself) (and for and on behalf of my child-participant if said child is not 18 years of age or older) do hereby release, forever discharge and agree to hold harmless BranchCreek Community Church and the representative thereof from any and all liability, claims or demands for personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and/or the child-participant that occur while said individual is participating in the above-described trip or activity.
Furthermore, we (I) [and on behalf of our (my) child-participant if under the age of 18 years] hereby assume all risk of personal injury, sickness, death, damage and expense as a result of participation in recreation and work activities involved therein.
Further, authorization and permission is hereby given to said organization to furnish any necessary transportation, food and lodging for this participant.
The undersigned further hereby agree to hold harmless and indemnify said organization, its representatives, employees and agents, for any liability sustained by said organization as a result of the negligent, willful or intentional acts of said participant, including expenses incurred attendant thereto.
_________________________________
Name of Participant
_________________________________ ________________
Signature Date
(If the participant has not attained the age of 18 years):
We (I) are the parent(s) or legal guardian(s) of this participant, and hereby grant our (my) permission for him (her) to participate fully in said trip, and hereby give our (my) permission to take said participant to a doctor or hospital and hereby authorize medical treatment, including but not in limitation to emergency surgery or medical treatment, and assume the responsibility of all medical bills, if any.
Further, should it be necessary for the participant to return home due to medical reasons, disciplinary action or otherwise, we (I) hereby assume all transportation costs.
Signature of Parent or Guardian:______________________ Home Phone __________________
Emergency Contact:_______________________ Emergency Phone #:_______________
Sample Sponsor letter:
Dear Friend,
From January 8 - 15, I will be a part of a team sponsored by BranchCreek Community Church that will be helping with relief efforts in Haiti. While there, we will be providing working with an in-country organization to help rebuild a church school and work with an orphanage.
The trip will cost approximately $1300 per team member. I am responsible for helping to raise funds to cover the cost of the trip. Would you consider joining our team by helping me with these costs? Not everyone has the ability or desire to labor in this way but your support will help make this trip possible for us and will make you as much a part of the team as those who will travel with us. If you would like to help, please complete the enclosed postcard and return it to me along with your contribution or mail it to the following address:
BranchCreek Community Church
ATTN: Kathy Nomides
100 Main Street
Harleysville, PA 19438
All checks should be made payable to “BranchCreek Community Church” and include the note “Mission-Haiti” in the memo field. Alternatively you may contribute using the secure online portal found at give. Simply follow these instructions:
1) Click on “Give Online.”
2) If you do not currently have access to the site, you will need to create username and password. Simply click on “Need a login”.
3) In the “Give To” drop-down, select “Mission-Haiti”
4) Enter the contribution amount.
5) Type my name in the Optional Memo field.
6) Click “Add” to add the contribution and then “Give” to complete the contribution process and enter your credit card or electronic check information.
Gifts to the church, with an expression of preference for my trip expenses, are tax deductible to the extent allowed by law. All monies collected above and beyond my costs will be used solely for the continuing work in Haiti, and if I am unable participate for some reason, your gifts will still be used for relief efforts in Haiti. **
Whether or not you feel led to support us financially, perhaps you would consider being part of our prayer support team. We would like to have a team of people covering us with prayer during our preparation time as well as during the actual trip. Either way please complete the enclosed form and return it as soon as possible to the above address.
In addition, our team is collecting donations of multivitamins with iron, nonprescription pain relievers and nonprescription antacids. Perhaps you could help out by donating some of these much needed supplies. I would be happy to get your donation to the team.
If you have any questions, please feel free to contact me or our team leaders, Kathy Nomides (Kathy.nomides@) or Jennifer Nomides (jnomides22@ ).
Sincerely,
** Please note: Bold text in the letter above is mandatory for text deductible purposes. Please feel free to personalize this letter and make if your own otherwise.
Response Card
□ We want to support the efforts of BranchCreek Community Church in Haiti and are sending our gifts of $______________
Our preference is that this gift be used to support _____________. We understand that the use of the gift is subject to the discretion and control of BranchCreek Community Church.
□ We would like to be added to your prayer team.
□ We would like to receive email updates. Email address: ___________________________
Name:
Address:
................
................
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