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 pbuck@equalexchange.coop   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 ___________________________________________________________________________________