SuNica Trip Application
2. First & Middle Name (as they appear on your passport)
3. Last Name (as it appears on your passport)
Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Year 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019
5. Please list your preferred airport(s) in order of preference. (ie: the airport(s) you want to fly out of)
6. Do you have a current US Passport? (If not - please apply for one now. You cannot travel to Nicaragua without one)
7. Street Address
- Select - Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Marianas Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming
10. Zip Code
- Select - Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Caribbean Netherlands Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo (Brazzaville) Congo (Kinshasa) Cook Islands Costa Rica Croatia Cuba Curaçao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong S.A.R., China Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Ivory Coast Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao S.A.R., China Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands North Korea Norway Oman Pakistan Palau Palestinian Territory Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Saint Barthélemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu U.S. Virgin Islands Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican Venezuela Vietnam Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe
12. Home Phone
13. Cell Phone
16. How did you hear about this trip?
17. Have you had previous experience on the mission field or traveled in a foreign country?
If yes, please list countries and experience.
18. What are your expectations for this trip?
19. Please describe your health, including physical or dietary limitations.
20. Are you on regular medications or currently under a doctor's care?
21. Please list any allergies (food, medicine, environment, insect, etc.)
22. Date of Last Tetanus (skip if you don't know)
23. Blood Type (skip if you don't know)
- None - Group A Group B Group AB Group O
24. This trip may require strenuous physical activity for extended periods of time. Do you have any conditions (medical or otherwise) that may prevent you from fully participating?
If yes, please briefly explain.
25. Please list any medical, First Aid, or CPR training.
26. Special Talent or gifting? (i.e.: musical, sports, professional, ministerial)
27. Is there anything else we should know about you?
Please list a character reference that we may contact.
Release of Liability and Release to Obtain Medical Care
Matthew 18:15-20 and 1 Corinthians 6:1-8 instruct us to live at peace and to resolve disputes in private or within the Christian church. Agreeing with this, I acknowledge my concern that the limited charitable resources of SuNica should not be dissipated on wasteful litigation. Therefore, I expressly waive my right to file a lawsuit for any reason in any civil court or other secular setting against SuNica, other nonprofit organizations and all individuals involved with this mission trip.
I realize that there are hazards, and I am fully assuming these risks which include but are not limited to: hazardous travel, poorly constructed roads, dangers resulting from military or political activities, sickness, disease, inadequate health care, kidnapping, arbitrary imprisonment, and all other unforeseen risks. I specifically release SuNica and all others concerned from any claim of negligence in their duties as leaders, or otherwise, on this mission trip. In the event that I attempt to make a claim in violation of my release and waiver as herein indicated I hereby agree to, and shall pay, all legal fees and costs incurred by SuNica and other individuals and organizations involved. I further agree that such claim or dispute arising from or related to this trip shall be settled by biblically based mediation as specifically described in the then-current Rules of Procedure for Christian Conciliation of the Institute for Christian Conciliation (
http://www.peacemaker.net/ICC), and if not resolved by said mediation, then by legally binding arbitration in accordance with the aforementioned Rules of Procedure for Christian Conciliation.
I hereby further acknowledge my responsibility to provide my own insurance coverage of any and all types, including but not limited to medical, hospitalization, life, disability, lost baggage, lost or stolen personal property, and any and all other insurance which I may need or desire. I also hereby release SuNica and all leaders and nonprofit organizations involved with this mission trip from responsibility to provide insurance coverage of any and all types. I hereby further authorize the leadership of SuNica to make essential decisions on my behalf with respect to medical treatment, emergency surgery, or hospitalization, should such be necessary. However, SuNica shall in no way be responsible or liable for payment of any and all bills for such medical treatment. I assume the full responsibility for any and all medical bills incurred during or in relation to this mission trip. I further agree wholeheartedly to abide by decisions made by leaders and those in authority and by all guidelines, policies, and rules pertaining to this trip.
I have read and I am in full agreement with this release and waiver, and fully understand that I am: waiving any rights I may have to litigate and sue and instead accepting biblically-based mediation to resolve disputes; accepting full responsibility for all insurance, all medical costs, and all risks related to this trip; authorizing SuNica leaders to make medical decisions if necessary; and agreeing to read and abide by all guidelines, policies, rules, and leadership decisions pertaining to this mission trip. I certify that all the information I have given on this form is accurate and true to the best of my knowledge.
In order to have us hold your spot on this trip, please immediately submit a non-refundable deposit of $250. It may be necessary to pay in full or pay 50% depending on the timeline to departure.
If you decide to mail a check, please do so within 3 business days. Thank you.
Make send check to:
Su Nica, Inc.
303 Tiffany Cir.
Garner, NC 27529