Personal information 

Name as it appears on passport:

Please note: Failure to provide your exact name as it appears on your passport will result in an additional change of name fee of $350.

Preferred name:

Gender:

Date of birth (day/month/year):

T-shirt size:

               

Passport information

If your passport expires between September 2017 and September 2018, please leave this section blank and apply for a new passport immediately.

Do you need to apply for a new passport?

               

Passport number:

Passport expiry date (day/month/year):
 

Nationality:
  
  

Contact information

Mount A e-mail:
  

Alternate e-mail:

Home phone number:

Cell phone number:

Home address:
 

Mount A mailbox:
 
  

Health information

Health insurance provider name:

Health insurance plan number:

Individual health insurance number:

Vaccinations — please check all that are up-to-date:

        

 Will you receive anti-malaria medication(s) from your own doctor?

             

Please list any dietary restrictions [allergy, personal food choice (vegetarian etc.), any food that cannot be consumed due to religious beliefs or other].
 
 
Please list any medical conditions or medications you will be taking during the brigade. (This information will remain completely confidential).
 
  

Emergency contact

Two emergency contacts are required.

Emergency contact 1
 

Name:
 

Relationship:

Phone number:

E-mail:

Emergency contact 2

Name:

Relationship:

Phone number:

E-mail:
 
 

Authorization

Are you a returning Global Brigades member?

           

Use of personal information
The personal information on this form is being collected by the University for the purposes of the Mount Allison Global Brigades trip to Honduras in February 2018. Once the information is submitted, it will automatically be e-mailed to the administrative assistant in Student Affairs.

Some of the information, such as the name, passport number, date of birth, and passport expiry date, will be provided to the group’s student travel co-ordinator and to a travel agency so that travel arrangements can be made.

All of the information will be taken by a University employee on the trip so that the information will be available in the event of emergency. During the trip the information will always be in the possession of someone in your brigade, either with a University employee or with a member of the group’s executive if a University employee is not present.

The information will be destroyed once the trip is completed.
 
By checking this box you certify that the information you have submitted above is correct and you confirm that you understand and consent to the uses that will be made of the information as described above.