Name
*
First Name
Last Name
Age
*
Sex
*
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Your Preferred Email
*
Your Preferred Phone
*
(###)
###
####
What are the name/names of the child/children that you sponsor at Rehema Home?
*
Have you ever been to Rehema Home before? If so, when?
*
Were you planning on bringing any family members with you on this trip? If yes, please list their names and ages.
*
Besides spending time with the child you sponsor, what other hopes/expectations to you have for this trip?
*
Do you have a valid passport?
*
If you do have a valid passport, please provide the following information:
Name (as printed on your passport)
Passport Number
Expiration Date
Issue Date
Birthdate
*
MM
DD
YYYY
Citizenship
*
Have you participated in any overseas travel experiences in the past?
*
If you have, please provide the following information about your two most recent trips:
Country, Length of Trip, Reason for Trip (Missions, Business, Pleasure, etc.)
List any major illnesses you’ve had in the past three years:
*
List any physical or emotional limitations/disabilities/restrictions:
*
List any allergies:
*
List any dietary restrictions:
*
Have you ever been convicted of a misdemeanor or felony?
*
If yes, please explain:
Primary Emergency Contact
*
First Name
Last Name
Relation
*
Telephone (cell)
*
Telephone (work)
*
Email
*
Secondary Emergency Contact
*
First Name
Last Name
Relation
*
Telephone (cell)
*
Telephone (work)
*
Email
*
