Eyes on Africa Foundation
Summer 2008 Trip to South Africa
Name: __________________________________ Sex:____ Age:_____ Date of Birth:_____________
(Last)
(First) (Middle Initial)
Address: ______________________________________ State:_____ Zip Code: __________
(Number,
Street, Apartment #) (City)
Home Phone: ____________________ Cell Phone: _______________________
Email:________________________________
Parent/Legal Guardian:_______________________________________________________________
(Name
– Please Print) (Contact
# if different)
Emergency Contact:
1.
Name:
_____________________ Relationship:
______ Phone(H):_____________(W)_____________
2.
Name:
_____________________ Relationship:
______ Phone(H):_____________(W)_____________
Trip (circle) May 25-June
11
or
May 29-June 15
A ÒWaiver and Complete Release of LiabilityÓ will be
required for trip participation and will be forwarded to volunteer participant
for completion once trip application and funds are received.
________________________________________________
________________________________
(VolunteerÕs signature) (Date
signed)
The Eyes on
Africa Foundation thanks you for your participation! You should
receive an email from us upon our receiving your package. Please mail or personally
deliver this package with your included check of $3700.00 to The Eyes on Africa
Foundation Attn: Mr. Thomas Egbert, CFO Checks can be made payable to the 501 College Avenue CPO-721 Eyes on Africa Foundation Wheaton, IL 60187