If you would like to join us for more than one leg, please mark accordingly.
PERSONAL INFORMATION
Name *
Name
Address *
Address
Phone *
Phone
Country Code will be +(...) ie, US = +1
Date of Birth *
Date of Birth
PASSPORT INFORMATION
Expiration Date *
Expiration Date
Please note your passport must be more than 6 months before expiration to enter South Africa.
EMERGENCY CONTACT INFORMATION
Emergency Contact *
Emergency Contact
Please list someone not traveling with you
Phone Number *
Phone Number
Country Code will be +(...) ie, US = +1
MEDICAL/INSURANCE INFORMATION
Do you have medical insurance? *
Primary Care Provider *
Primary Care Provider
Phone Number
Phone Number
Country Code will be +(...) ie, US = +1
Y or N . If Y, please list below.
Y or N . If Y, please list below.
LIABILITY RELEASE
I hereby declare that: *
If not yet 18, please have parents fill out youth release affidavit. Parents and youth must initial and sign the application.
I hereby declare that: *
I hereby declare that: *
I hereby declare that: *
I hereby declare that: *
I hereby declare that: *
By typing your name below, you agree that: *
By typing your name below, you agree that:
I accept and assume all risks and hazard from this activity, both known and unknown, including but not limited to the risks and hazards previously indicated. I hereby voluntarily release, forever discharge, and agree to hold harmless and indemnify Crestwood Vineyard Church, its directors, pastors, leadership, board, volunteers, and other team members from any and all liability, claims, demands, actions or rights of actions, Which are related to, arise out of, or are in any way connected With my participation in this activity, Which I now have or may have in the future, specifically including but not limited to the negligent acts or omissions of any person so released, held harmless and indemnified, and specifically including claims relating to any personal injury that I may suffer. I agree not to make a claim, file suit or demand anything from any injury, death or loss that arises from my participation in this activity. I agree to pay the costs and/or legal expenses incurred by the trip leaders, organizers, and/or participants as a result of any claim suit filed by me, filed by anyone else as a result of my conduct. I consent and agree to pay for any medical treatment rendered to me by anyone for any injury other medical situation during, or resulting from my participation. I authorize Crestwood Vineyard to arrange for transportation, and lodging for me on this trip. If these travel arrangements do not work for me, I agree to providing my own transportation at my cost. I acknowledge that I am responsible for all costs for transportation, food, lodging, etc. I agree that these promises, agreements; assumptions of risk and releases bind me, my family, all minors With me 01' on whose behalf I sign, and my heirs or legal representatives and assigns.