North West Haiti Christian Mission LogoNorthwest Haiti Christian Mission Trip Registration

USER ACCOUNT REGISTRATION

All fields not marked optional are required in order to register a user account!

Once logged in you will be able to update your profle to provide additional details.

REGISTRATION FORM
Is this the first time you have been on a mission trip with North West Haiti Christian Mission?
Username
Password
Confirm Password
PLEASE ENTER ALL INFORMATION
EXACTLY AS IT APPEARS ON YOUR PASSPORT.
First Name
Middle:
Last Name
Email address
Address
City
State
Postal Code
Country
Home Phone
Gender    
T-Shirt Size
Emergency Contact Information
Name:
Relationship:
Telephone (please provide two separate phone numbers): #1:
#2:
Health Insurance Information
Insurance Company Name:
Insurance Policy #:
Insurance ID # (optional):
Insurance Contact Phone #:
Other Insurance Information (optional):
Some Travel Information
Passport Number (optional)
Passport Country (optional)
Airport Departure City

Terms and conditions:

By clicking the "Submit" button below, to submit my registration information and acquire a login, I certify that I am at least 18 years of age and competent to sign my own name OR, if I am under 18, that I have requested the Permission for Minors form from the travel office – trips@nwhcm.org to complete the application process.

I do hereby certify that I am willing, physically and mentally fit, and sufficiently prepared to travel with and participate in a work project with the Northwest Haiti Christian Mission, in the country of Haiti. I have provided the necessary medical insurance information required by NWHCM, and the trip sponsors have my permission to take me to a doctor for medical treatment, hospitalization, or emergency surgery if the need should arise. Should it be necessary for me to return home prematurely for medical reasons or due to disciplinary action, I will assume total responsibility for any additional costs incurred.

I also understand that there are inherent risks involved in any mission trip, and I hereby release Northwest Haiti Christian Mission, its staff and volunteers from any and all liability due to any injury, loss or damage to person or property that may occur during the course of my involvement with Northwest Haiti Christian Mission.

I have carefully read and agree to abide by the regulations/guidelines and information included in the Team Member Packet. Packet can be downloaded on our main web-site – www.nwhcm.org. It is found under traveler information in the Go section of the web-site. A hard copy can be requested from the travel office – trips@nwhcm.org. I understand that my failure to abide by those guidelines forfeits my chance to participate in future trips with Northwest Haiti Christian Mission, and may result in early dismissal from any trip at my own expense.

 

CREDITS: Registration system developed by CrossRoads Missions. Authentication software by Easebay Resources. All other elements Copyright © 2011 - 2019 ~ Northwest Haiti Christian Mission, Zionsville, IN, 46077 ~ CONTACT US

Registration Software Version 1.0 - [nwhcm]