1Personal Information2Emergency Contact Information3Medical Information4International Flight Information Trip*What trip are you participating on? Specialty* Email Address* Phone Number*Name Exactly as It Appears on Passport* Date of Birth* MM slash DD slash YYYY Biological Sex Female Male Passport Number* Passport Date of Expiration*Passport must be valid for 6 months after last day of trip. MM slash DD slash YYYY Nationality* Place of Birth* State of Residence*Must have current license or proof of residence in the state. Address* Street Address City State / Province / Region ZIP / Postal Code Shirt Size*Women's Extra SmallWomen's SmallWomen's MediumWomen's LargeWomen's Extra LargeMen's SmallMen's MediumMen's LargeMen's Extra Large Emergency Contact Name* Relationship* Emergency Contact Telephone Number(s)*Emergency Contact Email* Emergency Contact Address* Street Address City State / Province / Region ZIP / Postal Code Are you currently taking any medication(s)? Yes No If you answered 'Yes', please list medications here: Do you have any medically-related dietary requirements? If so, please indicate here: Please list any other pertinent information regarding your health that we should know about: Which airport will you be departing from?* International Flight Arrival Agreement* I certify that my international flight arriving in the final destination for the trip lands at or before the required time as indicated on the "Suggested Flight Itinerary" document. I agree to meet the trip leader at the baggage claim of the airport, unless I am otherwise notified. If my flights are delayed for any reason, I will notify the Trip Leader and Project C.U.R.E. Travel Department as soon as possible. If I fail to arrive in-country at the required time, I will be responsible for any additional transportation and/or accommodation costs my late arrival causes. Do you have international travel insurance?*Project C.U.R.E. will provide travel insurance including medical evacuation coverage for all participants unless you specify here that you already have this coverage. Yes No Agreement* I CERTIFY that all statements and information furnished in this Statement are true, complete, and correct to the best of my knowledge and belief, and are made in good faith. I understand that statements or information furnished on this form are subject to verification and I agree to furnish supporting documents or information when so requested and/or names, addresses, and phone numbers (if known) of officials or other individuals who can substantiate the qualifications described above. I also understand that intentional misstatements or falsification will result in disqualification.
