Preliminary Participant Profile

Fields marked with * are required.
Name Last Name*
First Name*
Middle Initials

Address
(Please include city, state and zip)

Street:
City:
State: Zip:

Contact Phone Number (Day):

Contact Phone Number (Evening):
Cell Phone:
Fax:

Email*:

   
Emergency Contact  
Name Last Name*
First Name*
Middle Initials
Address
(Please include city, state and zip)		 Street:
City:
State: Zip:

Telephone Number*:
Relationship:
   
   
Please indicate your profession:
   
Do you have a valid U.S. Passport*?

Yes

No
   
   
Have you traveled overseas before?

Yes If yes, please list countries & Year(s)

No
   
Allergies: Please list any allergies
   
FBC Member

Yes

No
   
Air Travel Experience  
  What is the longest flight you have previously taken?
 
Do you belong to Delta Airlines Frequent Flyer program? Yes If yes, please provide number

No
   
Seat Preference Window

Aisle
   
Seatmate Name Request
   
   
Areas of Interest:

Church

Medical

Education

Cultural
   
We are currently rescheduling the dates for the FBC Ghana trips.

To help us better plan future trips, please let us know which quarter of the year you are interested in traveling. We will be publishing specific dates shortly.

2008

3rd quarter 4th quarter

2009

1st quarter 2nd quarter 3rd quarter 4th quarter

 

   
   

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