Trip Application

INFORMATIONAL APPLICATION
CORE JOURNEY TO VIET NAM: SPRING 2017

Please note that this is information needed only to organize travel with a group of veterans and civilians to Viet Nam. This is the first step in the process, which may also involve a personal conference call with the trip facilitators who will accompany the group and offer mentoring before, during, and after the trip. Details of how the travel experience is conducted will be explained during the call, however you may call before sending this information if desired; 303-909-8336.

FULL NAME:

____________________________________________________________________________________
(exactly as it appears on your passport)

PASSPORT NUMBER and DATE OF EXPIRATION

________________________________________________________________
A passport is necessary for travel to Viet Nam. If you don’t have one when will you be applying for one?

___________________________________________________________________

DATE OF BIRTH _______/_______/_______

STREET ADDRESS

____________________________________________________________________________________

CITY, STATE, ZIP

____________________________________________________________________________________

BEST TELEPHONE NUMBER

___________________________________________________________________________________

EMAIL ADDRESS

____________________________________________________________________________________

HOW DID YOU LEARN ABOUT THIS TRIP?

____________________________________________________________________________________

____________________________________________________________________________________

TYPE OF WORK

____________________________________________________________________________________
(present and/or former)

EDUCATION (any degrees)

____________________________________________________________________________________

WHY DO YOU WANT TO TRAVEL TO VIET NAM?

____________________________________________________________________________________

____________________________________________________________________________________
(expectations for the trip)

MEDICAL EMERGENCY CONTACT PERSON

___________________________________________________________________________________

CONTACT PERSON BEST TELEPHONE AND EMAIL

___________________________________________________________________________________

DO YOU HAVE HEALTH ISSUES THE TRIP FACILITATORS SHOULD BE AWARE OF?

___________________________________________________________________________________

____________________________________________________________________________________

WHAT ELSE WOULD YOU LIKE TO ADD?

___________________________________________________________________________________

____________________________________________________________________________________

VETERAN QUESTIONS 

(non veterans please continue at the bottom of the application for signature)

WHAT BRANCH OF THE MILITARY DID YOU SERVE?

__________________________________________________

WHAT WERE YOUR DUTIES?

___________________________________________________________________________________

___________________________________________________________________________________

IF YOU SERVED IN A WAR, WHERE, WHAT UNIT, WHEN?

____________________________________________________________________________________

____________________________________________________________________________________

___________________________________________________________________________________

 

DO YOU HAVE ANY ILLNESS/DISABILITY FROM THE WAR? (IF SO, PLEASE EXPLAIN)

____________________________________________________________________________________

____________________________________________________________________________________
(include emotional and chemical exposure disability)

IF YOU SERVED IN VIETNAM, WHAT WOULD YOU LIKE TO SEE OR DO ON THIS TRIP?

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

FUNDS ARE AVAILABLE TO VETERANS NEEDING ASSISTANCE ON THE TOTAL TRIP COST OF $5,000.

WILL YOU NEED A REDUCTION AND, IF SO, HOW MUCH WILL YOU NEED?

____________________________________________________________________________________

ALL APPLICANTS PLEASE COMPLETE SIGNATURE PORTION

_____________________________________________________
PRINT NAME

_____________________________________________________
SIGNATURE

_____________________________________________________
DATE

Please print and mail completed application to: CORE,
c/o Dr. John Fisher, PO Box 11, Jefferson, ME 04348

You may also scan a personally SIGNED digital copy and email to:

http://www.corevietnaminfo@gmail.com