ࡱ> FHE'` 'bjbjDD 76&&'88884l,$Mh V<LLL<QL^L @ [8g0 !8R ! !ddd<<(LLLL GREATER MILWAUKEE SYNOD APPLICATION FOR PARTICIPATION IN A DELEGATION TO EL SALVADOR & HOLD HARMLESS AGREEMENT Please complete the following and return it to Linda Muth at  HYPERLINK "mailto:info@partnerswithelsalvador.org" info@partnerswithelsalvador.org or mail it to Linda at St. Johns ELCA + 20275 Davidson Rd. + Brookfield 53045. Title and Dates of Delegation Trip: Mission of Healing and Wellness February ___ to February _____, 2011 Please fill in the blanks above according to the following (Advance Team will arrive in ES on Feb 3) (Regular Delegation Team will arrive in ES on Feb 5) (Regular Delegation Team will depart from ES on Feb 12 or 13) (Post-Clinic Team will depart from ES on Feb 15) _________________________________________________________________________________ Name ____________________________________________ __________________________________ Your passport number and country of citizenship Your Date of Birth _________________________________________________________________________________ Your Street Address ____________________________________________ ___________________________________ Your Email Address Your phone number ____________________________________________ Your Cell Phone Number ____________________________________________ _____________________________________________ Your Congregation Your Sister Church in El Salvador (if applicable) Do you speak or read any Spanish? If so, please indicate whether or not you are fluent or are willing to serve as a translator. (You do not need to speak Spanish in order to be a member of this delegation.) Are you a medical professional? If so, attach photocopy of current license to practice. [ ] Yes [ ] No Do you have healing gifts in the area of prayer healing, massage, eastern medicine, working with children or any other gifts which you would like to share during the mission. Please describe: Briefly state why you would like to be a member of this delegation to El Salvador. Are you interested in being a part of the Advance Team? [ ] Yes [ ] No Why? Are you interested in being a part of the Post-Clinic Team? [ ] Yes [ ] No Why? Are you in good health and in good physical condition? If you have any physical conditions which might be impacted by heat, extended walking, walking on rough terrain, and irregular mealtimes, please briefly describe your situation. Please list all allergies, including allergies to medications: Do you carry an epi-pen or other medications which may need to be administered by others in an emergency? Please indicate any dietary restrictions which you have (including whether or not you are a vegetarian): Have you traveled to El Salvador before? [ ] Yes [ ] No If yes, please describe: If you have participated in the Mission of Healing in the past, please take a few moments to write down your suggestions for must do or must include for the 2011 mission. Please read and complete the following: I, (print name) ________________________________________________, have voluntarily decided to join a Delegation to El Salvador. I am aware of the greater than normal risk to my well-being due to the possibility of problems of travel within, to and from El Salvador. I accept responsibility for obtaining appropriate insurance which will allow for my care and possible evacuation to the United States in case of a medical emergency. I, my heirs, assigns, representatives and executors hereby release and promise to hold harmless The Greater Milwaukee Synod of the ELCA and all other sponsoring group(s) and their officers, employees, advisors, agents, or representatives from any bodily or mental harm, injury, loss, or illness - including, but not limited to, death that may result from my participation in this Delegation, whether in El Salvador, in any travel to or from El Salvador, or upon my return. ______________________________________________________________ __________________ Your Signature Date __________________________________ __________________________________ ____________ Print Name of Witness Signature of Witness Date In case of emergency, please notify: ______________________________________________ __________________________ Name of Emergency Contact in the US Contact Relationship Emergency Contact Day Phone: _____________________ ______ Emergency Contact Night Phone: ___________________________ Emergency Contact's E-mail Address:_________________________________________ ___________________________________________________________________________________ Emergency Contacts Street Address Applications will be reviewed and accepted by the delegation leaders. Applications will be accepted on a first-come, first-served basis. Applications will be securely held and will be shredded upon the conclusion of the delegation trip. 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