Chiapas Application

Justice & Coffee Delegation Application, 1 of 4

Witness for Peace  3628 12th Street NE, Washington, DC 20017  202.547.6112 Travel Program Application

Globalization, Coffee and Justice in Chiapas, Mexico January 24 – February 3, 2009 A delegation for people of faith, sponsored by the Jubilee Justice Task Force of the United Church of Christ, Brethren Witness/Washington Office of the Church of the Brethren and the Interfaith Program of Equal Exchange

To complete this application on your computer, type over the lines, and check the boxes [x]. To complete the form by hand, print it out and mail or fax it. Please return this application to Peter Buck, Equal Exchange, 50 United Drive, West Bridgewater, MA 02379 By Email to [email protected]   By Fax to 508 587 5955

Name: First, Middle, Family ___________________________________________________________________ Address1__________________________________________________________________________________ Address___________________________________________________________________________________ City _____________________________________________________________________________________ State, Zip Code, Country ____________________________________________________________________ Primary Phone Number ______________________________________________________________________ Alternate Phone Number _____________________________________________________________________ E-mail ___________________________________________________________________________________ Date of Birth: [month/day/year] _______________________________________________________________ Birthplace: City, State, Country________________________________________________________________ Gender:  [] Female  [] Male Occupation:_______________________________________________________________________________ Passport No & Expiration Date_________________________________________________________________ How did you hear about this delegation? (indicate): [] Advertisement   [] Mailing   [] From a Friend    [] Internet   [] Other Health and Emergency Information: 1

If this is not your permanent address (for example, if it’s a college address) please enter your permanent address at the end of this form.

Justice & Coffee Delegation Application, 2 of 4

Negative answers to the following questions will not necessarily prevent you from being invited to travel with WFP. This information will help us in assessing your special needs and allow us to take measures which would reduce the risks of serious health matters during the course of the trip. Providing false information will result in dismissal from the program and Witness for Peace is not responsible for health issues that may occur during the course of the trip General Health (indicate one):   [] Excellent   [] Good   [] Fair   [] Poor 1.

List any dietary concerns: (e.g., vegetarian -- Please note that while there will usually be vegetarian options, vegan options are very difficult. Flexibility is necessary as it may be difficult to accommodate rigid dietary needs in areas where foods are difficult to get and local customs differ.)

_________________________________________________________________________________________ _________________________________________________________________________________________ 2.

Do you have any physical weaknesses, allergies, disabilities, illnesses that would impact your mobility on this delegation?

Choose one:  [] No  [] Yes -- please explain below: _________________________________________________________________________________________ _________________________________________________________________________________________ 3.

Do you have any history of drug and/or alcohol abuse?

Choose one:  [] No  [] Yes -- please explain below: _________________________________________________________________________________________ _________________________________________________________________________________________ 4.

Have you been hospitalized for an emotional or mental illness in the last two years? If so, are you currently under a physician's care or receiving prescribed medication for this condition?

Choose one:  [] No  [] Yes -- please explain below: _________________________________________________________________________________________ _________________________________________________________________________________________ 5.

Are you currently under a physician's care or receiving prescribed medication of any kind?

Choose one:  [] No  [] Yes -- please explain below: _________________________________________________________________________________________ _________________________________________________________________________________________

Justice & Coffee Delegation Application, 3 of 4

Emergency Contact: Whom should we contact in case of emergency? (Please make sure that the person knows to call the WFP office in Washington, DC if it is urgent that they get in touch with you.) Name: First, Middle, Family___________________________________________________________________ Street Address 1____________________________________________________________________________ Street Address 2____________________________________________________________________________ City _____________________________________________________________________________________ State, Zip Code, Country ____________________________________________________________________ Primary Phone Number ______________________________________________________________________ Alternate Phone Number _____________________________________________________________________ E-mail ___________________________________________________________________________________

Language and Travel: Spanish Language: (indicate one):   [] Fluent   [] Good   [] Fair   [] Minimal Have you ever traveled to Latin America or the Caribbean?: Choose one:   [] No  [] Yes – please share details below: _________________________________________________________________________________________ _________________________________________________________________________________________

References First Reference ____________________________________________________________________________ Indicate:  [] Friend   [] Co-Worker   [] Clergy   Years Known:_____________________________________ Phone ____________________________________________________________________________________ City, State ________________________________________________________________________________ Second Reference __________________________________________________________________________ Indicate:  [] Friend   [] Co-Worker   [] Clergy   Years Known:_____________________________________ Phone ____________________________________________________________________________________ City, State ________________________________________________________________________________

Justice & Coffee Delegation Application, 4 of 4

Commitments, Values and Beliefs: If you put answers on a separate sheets, please number them according to the questions. 1.

Briefly describe your experience with human rights, social justice, environmental, or other organizations that are committed to social change. (<150 words) Add details here, or on a separate sheet

2.

Are you a member of a congregation of faith (church, mosque, synagogue or other)?  

[] Yes   [] No. Name and location of Congregation_____________________________________________________________ _________________________________________________________________________________________ 3.

Have you or your congregation been involved with Witness for Peace?

[] Yes   [] No. Add details here, or on a separate sheet 4.

Have you or your congregation participated in the Equal Exchange Interfaith Coffee Program, or the UCC or Brethren Coffee Projects?

[] Yes   [] No. Add details here, or on a separate sheet 5.

What would you like to bring back to your community from this delegation? (insights, experiences, information, commitment or anything in particular you are seeking) Add details here, or on a separate sheet

6.

What is your position on non-violence? Add details here, or on a separate sheet

Permanent Address (if address at beginning of form isn’t your permanent address): Name: First, Middle, Family___________________________________________________________________ Address*__________________________________________________________________________________ Address__________________________________________________________________________________ City _____________________________________________________________________________________ State, Zip Code, Country ____________________________________________________________________ [Phone Number ____________________________________________________________________________ E-mail ___________________________________________________________________________________