registration and payment of deposit

A completed Registration Form and $100 deposit are required to hold a spot on a Just Go Haiti trip. If a trip becomes full, registrants will be placed on a waiting list in the order their registration form and deposit are received. You may register and pay your deposit here. Deposits are refundable until 60 days before travel.

Just Go Haiti Trip Registration Form

Trip Date

Name

First Name

Last Name

Date of Birth

YYYY

Email Address

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

FULL Name on Passport

Passport Number

Date of Passport Issue

Date of Passport Expiration

Emergency Contact & Number

Parent Name & Phone Number

Required if team member is under 18

Life Insurance Beneficiary

Required for Travel Insurance

Primary Care Physician & Number

Health Insurance Company

Policy Holder Name & Relationship

Health Insurance ID #

Health Insurance Group #

Medications you are taking

Allergies

PAY DEPOSIT

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