*Please help make our work easier by answering all questions!

***
Full Name:__________________________________________________________________
What you prefer to be called:___________________________________________________
Address:____________________________________________________________________
Phone Number:_________________________Email:_______________________________
Name of Organization/ Church/ Group:_________________________________________
Birth date:___________________ Passport Number:______________________________
Person to contact in case of Emergency:_________________________________________
Address and phone number of Emergency Contact:_______________________________
___________________________________________________________________________
Medical Problems of which we should be aware:__________________________________
Dietary Needs(including if Vegetarian):_________________________________________
Spanish Abilities:____________________________________________________________
Other Talents:______________________________________________________________
Work and/or place of study:___________________________________________________
Delegation date for travel to Nicaragua:_________________________________________
What do you hope to gain from this experience?__________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
What you hope to bring to this experience?______________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

AGREEMENTS
I,________________________________ willingly commit myself to complete the
agreements described bellow:
1. Each person that is part of the delegation must participate in all orientations.
2. Each delegate represents their organization(church, Rotary Club, University,
Other), delegation, and country, and therefore should maintain their composure
and respect in and for the delegation, as well as the customs and culture of their
sisters and brothers in the south.
3. Each delegate needs to express clearly his/her health limitations so that they can be
taken into account, and the team can better serve the delegates.
4. All the delegates must participate in all of the prepared activities; exceptions will
be made when previously negotiated through conversation with leadership of the
AKF team if justified reasons are given.
5. By accepting to participate in the trip to Nicaragua, I clearly accept responsibility
for my person and my belongings, and I release Escuela AKF from the risks and
consequences of the trip.
6. Delegates under the age of 18 must be accompanied by a parent or other adult
Guardian. In this case, both the signature of the adult Guardian and the delegate
must appear in the form. The signature of the delegate confirms that he/she agrees
to be accompanied by this adult.

Signature___________________________________

Date:_______________________