First Name (required)

Middle Name

Last Name (required)

Date of Birth (required)

Phone Number (required)

Your Email (required)

Marital Status (required)
MarriedSingleDivorcedWidower

Gender (required)
MaleFemale

Current Address (required)

How long have you resided at this address? (required)

Name and Phone number of emergency contact #1 (required)

Name and Phone number of emergency contact #2 (required)

Name of church you attend, if not applicable, please list none (required)

Address of church

Do you have a valid passport with at least three blank pages? (required)
YesNo

Exact Name on Passport (required)

Passport Number (required)

Passport Expiration Date (required)

Have you traveled to any country in Africa before(required)
YesNo

Health Insurance Provider (required)

Health Insurance Policy Number (required)

Primary Care Physician (required)

Primary Care Physician Address (required)

Primary Care Physician Phone (required)

Date of last medical exam (required)

List of any allergies? Medications, foods, other (if none, please state none): (required)

Do you have any medically mandated dietary restrictions (if none, please state none): (required)

Do you have any of the following? Diabetes, heart disease, hypoglycemia, epilepsy, high blood pressure, asthma? (if none, please state none): (required)
DiabetesHeart diseaseHypoglycemiaEpilepsyHigh blood pressureAsthmaNone

Do you have any ongoing or chronic health conditions other than the ones mentioned above? (required)
YesNo

Are you currently taking any prescription medication? If yes, please list them all and the condition they treat. (if none, please state none): (required)

Have you been charged or convicted of any misdemeanor or felony within the last ten years? (required)
YesNo

If yes, please provide the details:

The Center for Disease Control has a page regarding vaccines and medicines for individuals traveling to Malawi. The link is provided below. The specific type of vaccination or medicine required varies from person to person and they type of activities planned. We advise you speak to use the CDC website and your physician, and/or one of the BCV staff members to give you the best advice regarding your health preparations for this mission trip. https://wwwnc.cdc.gov/travel/destinations/traveler/none/malawi

I have contacted my personal physician or the Department of Public Health (404-657-2700) or the CDC website for Malawi and/or have received the necessary recommended shots needed to go on this mission trip. (required)
YesNo

APPLICATION AGREEMENT

I AGREE TO SERVE UNDER THE LEADERSHIP OF BWANALI CHIPOLE VICTORY INC I UNDERSTAND THAT MY APPLICATION IS TO BE ACCOMPANIED BY MAILING MY PASSPORT TO BCV INC, P.O BOX 352, ROSWELL GA 30077 FOR THE PURPOSES OF SECURING A TRAVEL VISA TO MALAWI. MY PASSPORT WILL BE MAILED BACK TO MY ADDRESS SUBMITTED ON THIS APPLICATION. I MUST ALLOW 4-6 WEEKS FROM WHEN I MAIL MY PASSPORT TO BCV INC UNTIL I RECEIVE MY PASSPORT BACK AS PROCESSING TIME. I ALSO UNDERSTAND THAT IF I DON’T HAVE A PASSPORT AT THE TIME I SUBMIT MY APPLICATION; IT IS MY RESPONSIBILITY TO APPLY FOR ONE IMMEDIATELY. I UNDERSTAND THAT I WILL NOT BE GRANTED ACTIVE STATUS FOR THE TRIP UNTIL APPLICATION, DEPOSIT AND MAILING OF THE PHYSICAL PASSPORT IS MADE TO BCV INC. I UNDERSTAND THAT IT IS MY RESPONSIBILITY TO CONSULT WITH BCV REGARDING THE PURCHASE OF MY FLIGHT TICKET. ADDITIONALLY, ANY EXPENSE THAT WILL OCCUR IN THE PROCESS OF THE APPLICATION CANNOT BE REFUNDED BY BCV INC.
AGREE: TYPE IN YOUR NAME FOR A SIGNATURE

I AGREE (required)

Mission Trip Personal Waiver /Release Statement
I understand that this is a mission trip, from/with Bwanali Chipole Victory, Inc, focused on partaking in education, feeding and empowerment opportunities of young children in Phalombe, Malawi. I release Bwanali Chipole Victory Inc, and its officers from liability for accidents, sickness, injury, death, or any adverse or otherwise unfortunate events during the course of, or as a result of the trip. I also release BCV Inc from responsibility for any lost or stolen possessions that might occur during the trip. I will abide by the authority and decisions made by BCV Inc.

I AGREE (required)

Please attach a copy of your passport (required)

Please attach a copy of your Drivers License or State issued ID (required)

Please attach a copy of your health insurance card or proof of active health insurance (required)

Additional questions or comments?

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