APPLICATION PACKET

AUGUST 2-9, 2016

UPCOMING DUE DATES

MAR 6

Deadline to return this completed application

($250 non-refundable deposit due)

APR 17

$400 due

JUNE 5

$450 due

JULY 12

FINAL $250 due

If booking your own flights, only $100 remaining due

Estimated Trip Cost: $1350

Please stay tuned for updates as trip details are fine-tuned and
arrangements are finalized.
Late payments may result in the cancellation of your application.
PLEASE MAKE SURE TO FILL OUT ALL FORMS WITH YOUR NAME AS IT
APPEARS OR WILL APPEAR ON YOUR U.S. PASSPORT.
IN ORDER TO ENSURE A SMOOTH TRANSITION THROUGH CUSTOMS, YOUR
AIRLINE TICKET AND PASSPORT NAMES SHOULD MATCH.
NO NICKNAMES OR ABBREVIATIONS, PLEASE.

APPLICATION
I do hereby submit this application to join World Harvest Outreach on a group trip to the country
of Costa Rica, during the dates of August 2-9, 2016.
* Husband and wife, please submit separate applications
NAME

_____________________________________________________________

ADDRESS

_____________________________________________________________
_____________________________________________________________

CELL PHONE

_____________________________________________________________

EMAIL

_____________________________________________________________

ARE YOU ON FACEBOOK?

YES

NO

PASSPORT NO. _____________________________________________________________

You must provide a copy of your valid passport with this application

TRAVEL ARRANGEMENTS:
DEPARTING ON WHO-PA FLIGHTS - $1350 PER PERSON
DEPARTING FROM ALTERNATE LOCATION - $750 PER PERSON
Those departing via other locations will be responsible to book their own air travel; please plan
to arrive at SJO Costa Rica on Tues, August 2 and to depart SJO on Tues August 9.
Send your flight itinerary to whocenter@whocenterpa as soon as you book.
Pickup at SJO will be arranged for you.

HEALTH INSURANCE:
COMPANY

_____________________________________________________________

GROUP/ACCOUNT __________________________________________________________
DO YOU HAVE ANY MEDICAL CONDITIONS WE SHOULD BE AWARE OF? ___________
DO YOU HAVE ANY ALLERGIES, INCLUDING DIETARY? ___________________________
Please do not list dietary preferences, as we may not able to accommodate them.

DATE OF LAST TETANUS SHOT: ________________________________________

IN CASE OF EMERGENCY:
CONTACT________________________________________ PHONE ____________________________

DETAILS
Refunds All Mission Trip payments made to World Harvest Outreach (WHO) are nonrefundable, as there are substantial expenses incurred prior to the travel date. Any cancellation
money unused for your trip, will be received by WHO as a donation, or may be held in trust
toward a future travel date (on a WHO trip only) not more than 24 months from the travel date.
Cancellation If a person must cancel their trip for legitimate reasons (e.g., medical or family
emergency) he or she does have the option to apply their payment amount to a future WHO trip,
or to designate another person to go in his/her place (both options available for 24 months from
the original departure date).
Transportation Delays WHO does not act as agent for any travel or transportation
corporation. WHO shall not be liable for any cost associated with transportation delays due to
weather conditions, civil disturbances, military actions, labor disputes, strikes, government
regulation, or any other reason beyond the control of either entity.
WHO do not act as guarantors regarding travel activities.
The applicant shall bear any and all costs associated with his/her transportation delays.
Waiver of Claim for Damages and Release of Liability In consideration of WHO granting me
permission to participate in a mission trip, I hereby waive any and all claims for damage or loss,
for personal injuries or property damage which may be caused by any act, or failure to act, of
WHO, its officers, directors, missionaries, agents and/or employees.
I acknowledge that WHO is not responsible to provide health care and I will be responsible for
expenses that could result of my participation on this trip.
By signing this application, I agree to the terms and conditions set forth herein, and this Waiver
and Release shall be binding upon spouse, my legal representatives, heirs and myself.
In witness where of, I have signed this Application this ____ day of _________________, _______.
_______________________________________
Signature of Applicant / Date

_______________________________________
Name of Witness (not related) / Date

If Applicant is a minor under the age of 18:

_______________________________________
Signature of Parent or Guardian / Date

_______________________________________
Relationship

In the event I am unable to communicate for myself, I hereby authorize emergency medical
treatment, surgery, or dental care to be given as considered advisable or necessary in the
judgment of an emergency medical professional or attending physician.
_________________________________________________________________________
Participant signature / Date (IF MINOR, then parent or guardian signature / Date)

CONSENT FOR INTERNATIONAL TRAVEL OF A MINOR

I, ___________________________________________ (name of parent/guardian), declare
that I am the lawful Guardian of _____________________________ (name of minor child),
______________________ (gender), born _____________________ (birthdate).
My child, _____________________________, has my consent to travel with World
Harvest Outreach of 1090 Wayne Ave, Chambersburg, Pennsylvania, 17201 (under the
care and supervision of Mark Durniak, Dawn Durniak, or another nominated officer) to
travel to: Heredia, Costa Rica from August 2 through August 9, 2016. My child will be
leaving the United States on or about August 2, 2016, and returning to the United States
August 9, 2016.
In the event that my child requires emergency medical treatment or immediate legal
representation and I cannot be reached, Mark Durniak, Dawn Durniak or a nominated
officer are/is authorized to act on my behalf.
Signed,
___________________________ (name of parent/ guardian)

________________ (date)

___________________________ (Mark Durniak)

________________ (date)

___________________________ (Dawn Durniak )

________________ (date)

Parent Emergency Contact Info:

Home Telephone:

(______) ______-________

Work Telephone:

(______) ______-________

Cellular Telephone: (______) ______-________

OPTIONAL FOREIGN TRAVEL INSURANCE

1 form needed per traveler. Married couples please fill out individual forms

_____ YES, I authorize World Harvest Outreach to purchase, on my behalf, an

international insurance policy for myself or my minor child in reference to the trip to
Costa Rica on August 2-9, 2016, at an additional ESTIMATED expense of $40
(varies by age).
Name of traveler (as it appears on U.S. Passport):

Birth date

________________________________________________________________________
Address:
________________________________________________________________________
________________________________________________________________________
IF YOU DECLINE COVERAGE, PLEASE INDICATE BELOW:
_____ NO, I decline coverage by any additional insurance policy.
____________________________________________________
Signature (if under 18, parent or guardian)

________________
Date