Builders of Hope July 5-11, 2009
Builders of Hope Trip
July 5-11
$150 (plus airfare)
In cooperation with Esperanza International
Tijuana, Mexico
June 20th is the last day to register
Member Information
Fill in All the Information below. You will not be considered signed up unless you have:
1. Paid
2. Filled in your Health Insurance Information.
3. Filled in your Emergency Contact Information
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First Name
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Last Name
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Cell Phone
Name of Emergency Contact
*
Relationship to you:(mother, father,..etc.) It
can not
be someone on the trip.
*
Emergency Contact Phone Number
*
YOUR
Email Address
*
I agree to abide by the C.W. Post Code of Conduct.
Yes
*
I have the following health issues: (write none if you have none)
*
I have the following allergies
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Health Insurance Company
*
Health Insurance Account Number
*
My health insurance covers International Travel.
Yes
No, I realize I must purchase special insurance
Payment Options
Your space is not secure unless you have paid. Although you have reserved online, you are not confirmed until there is payment. Spots are only held for 48 hours with out money.
*
I will pay by:
I will use a credit card online
I will pay at the chapel
You may pay online if you wish. You can use any major credit card.
To Pay Online (Non Refundable)
Application Fee $150
Flight Information
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Airline
*
Flight Number
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Arrival Date
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Arrival Time
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Departure Date
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Departure Time
For Office Use Only: Receipt Number
*
Indicates Response Required