Professional letter

No Boundaries Ministry
10435 Kerns Road Huntersville, North Carolina 28078 USA Phone 704-458-3696 Holy Land Tour Application
Date of Application ______/______/______
Trip Location: ISRAEL

General Information (Please print or type)
Full Name _______________________________________________________________________________
Current Address ____________________________________________________________ Apt. # _______
City_____________________ St____ Zip________ Phone (_____)_____________; (_____)____________
Email_______________________________________________ T-Shirt size________________________
Date of Birth_____/_____/______ Age_____ Sex: Male Female Marital Status_______________
Citizenship_______________ Passport #_______________________________ Exp. Date__________
Names and Phone # of 3 Family Members____________________________________________________
Referred by__________________________________________________________________
How did you hear about this trip?_________________________________________________

Signature __________________________________________________

A copy of the following documents must be submitted with the completed application form:

• Driver’s License
• Birth Certificate
• Passport
Return completed application form along with other required documents to:

No Boundaries Ministry, 10435 Kerns Road, Huntersville, NC 28078
Make checks payable to: No Boundaries Ministry
Confidential Medical History Form
Please answer al questions. Explain any ‘YES’ answers in the space provided below.
� Abnormal Blood Pressure

Females Only
� Irregular Periods
Explain ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Are you allergic to any of the following? If yes, please describe your reaction and how you treat it. Environmental Agents Foods �Insect Bites Medication (penicillin, aspirin, other drugs Other ________________________________________________________________________________________________________________________________________________________________________ Do you have any physical handicaps or health conditions that require special attention? Explain. ________________________________________________________________________________________________________________________________________________________________________ Are you now, or have you recently been, under a doctor’s care for any conditions? If yes, explain. ________________________________________________________________________________________________________________________________________________________________________ Do you presently take any medication on a regular basis? If yes, explain. ________________________________________________________________________________________________________________________________________________________________________ Notarized Consent Form for Adult
In case of unconsciousness, or inability to release myself for medical treatment resulting from an accident on the trip that requires medical attention, I, _________________________________, give my permission to No Boundaries Ministry, its representatives and all attending health care professionals (including but not limited to registered nurses, licensed practicing nurses, physicians’ assistants, doctors and paramedics) to hospitalize, anesthetize, or perform surgery on me as is required. I, ____________________________________, the undersigned, release, acquit, discharge and covenant to hold harmless No Boundaries Ministry and its representatives from all actions, damages or liabilities arising out of treatment of any sickness or accident incurred by my participation on the trip. It is the intention of this release that No Boundaries Ministry and its representatives incur no liability whatsoever while attempting to meet all medical needs that I may require during the trip. I understand that I am personally responsible for any medical expenses that may be incurred on my behalf. I hereby release No Boundaries Ministry its agents, employees, and volunteer assistants from any liability whatsoever arising out of an injury, damage, or loss which may be sustained by said person(s) during the course of involvement with No Boundaries Ministry. Dated this ___________ day of _________________, 20__. __________________________ Applicant’s Signature State of ______________________, County of _________________. Sworn to and subscribed to me this ____________ day of ____________________, 20___. Notary Public Signature __________________________________________________________________ My commission expires____________________


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