Getting to know you...

Whether you've been to Rehema Home before or not, we'd like to make sure we get to know you. You’re always welcome to reach out to the US Office, but completing this application is a great start as well!

Please complete the form below

General Information

Name

First Name

Last Name

Age

Sex

Male

Female

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Your Preferred Email

Your Preferred Phone

(###)

###

####

Personal Information

Have you ever been to Rehema Home before? If so, when and what did you do?

Were you planning on bringing any family members with you on this trip? If yes, please list their names and ages.

What hopes/expectations do you have for this trip?

Travel Information & History

Do you have a valid passport?

Yes

If you do have a valid passport, please provide the following information:

Name (as printed on your passport)

Passport Number

Expiration Date

Issue Date

Birthdate

YYYY

Citizenship

Have you participated in any overseas travel experiences in the past?

Yes

If you have, please provide the following information about your two most recent trips:

Country, Length of Trip, Reason for Trip (Missions, Business, Pleasure, etc.)

Health & Background Information

List any major illnesses you’ve had in the past three years:

List any physical or emotional limitations/disabilities/restrictions:

List any allergies:

List any dietary restrictions:

Have you ever been convicted of a misdemeanor or felony?

Yes

If yes, please explain:

Emergency Contact Information

Primary Emergency Contact

First Name

Last Name

Relation

Telephone (cell)

Telephone (work)

Secondary Emergency Contact

First Name

Last Name

Relation

Telephone (cell)

Telephone (work)

Getting to know you...

Please complete the form below

Connect

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