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HopeCo Mission Team Required Registration Form

Legal Full Name (as it will appear on your passport)

If you are traveling with a group, please specify which group.

Do you have a valid passport with an expiration date of at least 6 months AFTER your return?

Date of Birth (Month, Day, Year)

Gender

Preferred First Name

Phone

(###)

###

####

Street Address

City and State

Zip Code

Nearest International Airport

Please enter your weight. We need this for our flight data.

Your Primary Care Physician's First and Last Name

Your Primary Care Physician's Office Phone Number

Current List of Medications, including non-prescription (vitamins, supplements, etc)

Please detail any medical conditions (present or past) that would need to be shared with HopeCo or in-country medical staff.

Please list any physical disabilities or limitations.

Please list any allergies, including food allergies, and their reactions.

Please list any dietary restrictions.

Date of last tetanus shot (must be within the past 10 years).

Emergency Contact 1 (do not list anyone that will be on the trip with you): Name, Relationship to you, Phone Number, Email

Emergency Contact 2 (do not list anyone that will be on the trip with you): Name, Relationship to you, Phone Number, Email

Please read and agree to HopeCo's Consent and Medical Release

I hereby release and hold harmless HopeCo and any and all of its officers, directors, and team leaders of City of Hope, from all liability for personal injury, including death, as well as property damage or loss arising out of my or my child’s participation in this trip. I give consent for the leaders of this trip to authorize any medical treatment deemed necessary for me or my child by the aforementioned and the attending physician, including administration of medication, anesthesia, emergency surgery, or hospitalization. I agree to assume complete financial responsibility for all medical bills incurred by me or my child. This consent is signed in advance of any specific diagnosis, treatment, surgery, or hospital care required, but is given to provide authorization and specific consent for medical/dental treatment and care in my / my child’s behalf. Any consent by HopeCo or its officers/ directors shall have the same force and effect as if I had personally given the consent. I agree to assume total financial responsibility to travel home immediately if it is necessary for medical or any other emergency reasons.

Please read and agree to HopeCo's Mission Team Member Contract

We want your experience with HopeCo to bless you as well as the lives of those you meet – children, staff, and local people. To help this happen, we ask you to affirm your agreement to the following: 1. I understand that I am traveling under the umbrella of HopeCo, a non-denominational faith-based Christian organization. I agree that I am not here to promote any other organization or agenda. 2. I agree to stick with my team and follow the instructions of my team leader and the local staff even when I may not understand all the reasons why. I will never wander off alone and will let my leader or a staff member know where I am at all times. 3. I agree that if I have any problems or encounter something that I do not understand I will discuss it with my team leader or a member of staff at HopeCo. 4. I agree not to give or receive any gifts, either of money or personal items, to/from any individuals. (If you wish to give any gifts, it must be given through a team leader or City of Hope local staff member.) 5. I agree to avoid using any inappropriate language that may be viewed as crude or offensive. 6. I understand that computer, internet, and cell-phone use will be restricted to emergency use or by permission of a leader or local staff member for a specific purpose. 7. I agree to respect each person’s culture, foods, and way of life, including the Christian ethos that is reflected in HopeCo’s work. 8. I agree to adhere to the dress code as described in the mission team booklet. 9. I agree to restrict all medications, including over-the-counter creams, lotions, or medications to my personal use and not share them with team members, staff, children, or local people. 10. I agree to not become romantically attached to anyone during this trip. (If you are already romantically linked to a team member, please keep displays of affection limited when in public.) 11. I agree to abstain from illegal drugs, tobacco, alcoholic beverages, R or X-rated movies, and any form of pornography while at City of Hope. 12. I agree that HopeCo is not responsible for any lost or stolen items. I agree that I am entirely responsible for all my personal belongings. 13. I agree that all payments made to HopeCo are non-refundable. (While we may be able to give partial refunds under certain emergency circumstances where cancellations are made well in advance, many of the tickets are non-refundable and most expenses incurred are also non-refundable.) 14. I will not share personal contact information with any staff or child at City of Hope or take their contact information. I will send all communications to children or staff through the HopeCo office.

Please read and agree to HopeCo's Child Safeguarding Code of Conduct

As a mission team member working with HopeCo, I affirm that I have read HopeCo’s Child and Vulnerable Adult Safeguarding Policy and agree to abide by the following Code of Conduct: • I will conduct myself in a manner that is consistent with my position as a representative of HopeCo at all times • I will be a positive and helpful role model to the children I work with • I will be respectful of each child’s rights, background, culture, and beliefs • I will follow HopeCo’s policy, local laws, and any other good practice guidelines, and will implement adequate safeguards to avoid putting myself in a position where I might be accused of abuse or of otherwise putting children at risk • I will avoid any unnecessary or potentially abusive physical contact with children, including rough physical games or interactions with children that may be misinterpreted by others • I will use language that is appropriate to the situation and will avoid making suggestive comments to a child, even as a joke • I will avoid any actions or words that are intended to humiliate or belittle children • Taking or sharing of any photographs of children or vulnerable adults will be in accordance with HopeCo’s policy and any other guidelines I am provided with • I will undertake, to the best of my ability, to protect children in HopeCo’s care from any form of abuse and will immediately report any concerns that I have regarding child safeguarding issues to a member of staff • I recognize that, should the terms of HopeCo’s safeguarding policies be breached, immediate and appropriate action will be taken by HopeCo according to the provisions set out within the policy. I confirm that I have read and understood HopeCo’s safeguarding policy and guidelines for team members and volunteers. I agree to abide by these at all times with all children and vulnerable adults that I come into contact with, to protect both myself and them. I acknowledge that failure to comply with these standards may lead to the termination of my working relationship with HopeCo and the possibility of further action being taken.

Is there any additional information that HopeCo needs to know about you?

Email documents to Kristi Smith at kristi@joinhopeco.com

Email the following document: 1. A scan of your Passport Data Page Type "okay" to indicate understanding

PLEASE COMPLETE AND SUBMIT THE SECOND REQUIRED FORM

Please indicate which of the following skills you have and are willing to use while in Africa:

Name

First Name

Last Name

Carpentry

Plumbing

Electrical

Painting

Christian Ministry with Adults