Mission Trip Application Contact Information: First Name* Last Name* Birthday (MM/DD/YY)* Gender Male Female Address* City* State* AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI Zip Code* E-mail* Phone Number* Medical Information: Existing Medical Conditions, Allergies, or Other Dietary Needs* Medications* Medical Insurance Company* Policy Number* Policy Holder\'s Name* Relationship to Policy Holder Emergency Contact Information: Emergecy Contact #1 Name* Relationship* Primary Phone Number* Secondary Phone Number Email Address Address Emergecy Contact #2 Name* Relationship* Primary Phone Number* Secondary Phone Number Email Address Address I give Happiness Now permission to contact the individuals named above in the event of an emergency.* Yes Travel Information: Do you have a passport?* Yes No Applying Full Legal Name (As Displayed on Passport)* Passport Number* Expiration Date* Country of Issue* Are you a U.S. Citizen? Yes No Briefly explain why you would like to serve on this mission trip with Happiness Now:* Submit