Echo Cuba : Trip Application Form (English)

Background Information

Today's Date		Region Visiting

Tentative Trip Dates

Phone		Email

The Following Information
Should Be Listed EXACTLY As It Appears On Your Passport

Full Name

Home Address

Apartment

Country		City		State		Zip

Sex		Date of Birth

Marital Status

Occupation

Mother's Maiden Name

Passport Number

Passport Expiration Date

Contact In Case Of Emergency

Name

Relationship

Phone

Home Address

Apartment

Country		City		State		Zip

Additional Questions

How many times have you traveled from the US to Cuba?

When was the last time you went to Cuba for missionary purposes?

Which license did you use?

What is your reason for traveling to Cuba?

Check Those You Need Assistance With

	Itinerary
	Transportation
	Translator / Guide
	Lodging
	Flight Arrangements

Release of Liability and Approval of Ministry

If I am accepted, I will:

Adhere to all of the instructions and guidelines provided by the license provider regarding my trip, including the delivery of humanitarian aid to specified locations;
Keep a copy of my travel documents (i.e., flight ticket, authorization letter, etc.) for five years, should the authorities make an investigation;
Be responsible and prompt with all stated financial aspects related to my trip;
Participate in filling out a post-trip report for the license provider;
Wholeheartedly cooperate with staff, personnel, and representatives in the U.S. as well as Cuba.

In consideration for being accepted and allowed to participate in this project, and activities associated with its programs and locations, I personally assume responsibility for my actions, and release the license provider and any associated groups or ministries, their board members, employees, and missionaries from loss, injury, or damage to myself or my property; provided that nothing contained herein shall excuse the license provider and any associated groups or ministries, their board members, employees, and missionaries from the responsibility to act with reasonable care for the safety of myself or my property.

Typing your full name in this box constitutes your electronic signature:

Signed		Date