Team Trip Application Please complete the form below Select Trip * Kenya | Nov 2025 Widow's Trip | February 2026 Tanzania | April - July 2026 Name * First Name Last Name Date of Birth * MM DD YYYY Address Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Phone (###) ### #### How did you hear about Pamoja Love? * Why are you interested in participating in this trip? * Passport Information Passport Number Name listed as on Passport * First Name Last Name Passport Place of Issue * Passport Date of Issue * MM DD YYYY Passport Date of Expiration * MM DD YYYY Emergency Contact Info Name First Name Last Name Phone (###) ### #### Email Medical Information Healthcare Provider Name * First Name Last Name Physician's Name * First Name Last Name Phone * (###) ### #### Are you generally in good health? * Check any conditions or health concerns * AIDS Allergies Anemia Asthma Back Problems Cancer Depression Diabetes Epilepsy Fainting Spells Gallbladder Issues Heart Hepatits Low Blood Pressure High Blood Pressure Intestinal Kidney Mental Disorders Migraines / Headaches Nervous Disorders Recent Surgery IBS / Digestive / Ulcers Respiratory Tuberculosis Irregular Cycles / Heavy Menstrual Flow Are you pregnant? Severe Cramps? Please list any other health concerns not listed above * List all medications you are currently or will be taking * List all supplements you are taking * List any phobias you may have (heights, spiders, etc>) * Do you suffer from anxiety attacks? * Do you use any tobacco products? * Cannabis, CBD oil, hemp, marijuana is an illegal substance where we visit, do you use any of these? * Have you ever had a problem with substance abuse, drugs or alcohol? * Have you in the past or do you currently have any legal issues that may interfere with international travel? * Digital Signature + Date of Application by checking the box below I confirm that the above information is accurate and true, and that I have not left out information that could impact my participation on the team trip. * I agree Digital Signature (type legal name here) * First Name Last Name Date of application * MM DD YYYY Approved by Pamoja Love Director Name + Date: Passport check by Pamoja Love Passport date check Thank you!
