Team Participant Information Form

You have selected the trip Beginning on Mar 17 2022 The TeamiID is
The trip Mission is��Speech/Language Therapy (Univ. of Washington)
Name: IMPORTANT: Enter Name EXACTLY as it is found on your passport.  Don't assume, Please examine your passport BEFORE entering your name here. Enter Last First Middle no commas
Name
Birthdate(MO/DD/YYYY)
Mailing Address
Address2
City
State
Zip Code
Primary Phone
Cell Phone
Email Address
Alternate Email Address
(Students only! Please list an email address that is not associated with your school)
Occupation
(If Medical, please also complete Health Care Provider Information Form)
Number of Previous HIM Trips: IMPORTANT: Enter Only whole Numbers. If this is your first trip enter 0
#of previous HIM trips
  Numbers only! If this is your first trip enter 0
 
Gender
 
Knowledge of Spanish
Shirt Size
Team Participant Medical History

Parent's name
Parent's Phone
HEALTH INFORMATION
To be completed by all participants.
Mark your answer to the following questions. (if yes, Please Explain)
 
Your Current Health
Do you have any allergies(including medication, food or environmental allergies)? *   
Explain
Do you have any health problems? *   
Explain
Do you have any dietary restrictions? *   
Explain
Do you have any physical challenges that might require special assistance? *   
Explain
Are you Pregnant *   
 
List all current medications and dosage:
Personal Conduct

Personal Conduct Expectations
To be completed by all participants.
I will:
  • 1. Respect the Guatemalan culture.
  • 2. Respect other team members.
  • 3. NOT consume alchoholic beverates if I am under the age of 21.
  • 4. NOT use profane language.
  • 5. Refrain from posting anything on social media that does not align with HIM's mission and reputation
  • 6. Dress appropriately (No short shorts, crop tops or tube tops)
Emergency Contact Information

Emergency Contact Information
Contact Name
Relationship
Contact Primary Phone
How did you hear of Hearts in Motion?
 
Explain why you are interested in volunteering for Hearts in Motion and your expectation?
By checking the box, I grant Hearts in Motion ("HIM") permission to use my likeness in any photograph, video, any other digital media, and in any HIM publication, including any web-based publication (collectively the "Media"), without prior notice and without payment or other consideration. I understand and agree that all photos will become the property of HIM.
 
    I certify that to the best of my knowledge and belief the above information is true and complete and
I acknowledge that checking this box represents my legal signature and will be accepted by Hearts in Motion as my Legal Signature when applied to this document.
 
Date of digital signature?