Request edit access
2019 February Service Trip Registration
Come join us for our February Service Trip from Sunday, February 17th through Wednesday, February 20th at the NETS Campus in Williston, Vermont. 7th graders to adults welcome!

Below you will find our online registration. When completed, click the submit button at the bottom of the page.

Once you submit this form, you will be given the option to sign the Legal & Medical Release via an electronic signature service called 'Hello Sign'. You can choose to electronically sign the form, or print a copy and return it to the church office. If, for some reason, you are not directed to this page, you may reach it by selecting the "Sign Legal & Medical Release" button on the event page on the church website.

Questions? Contact the Christ Redeemer Church office at office@christredeemerchurch.org or 603-643-5588.

Family Information & Emergency Contacts
Family Name *
Your answer
Home Address *
Your answer
Home/ Cell Phone *
Your answer
Email Address (of parent or guardian if a minor) *
If more than one parent should receive emails about this event, please include both emails here.
Your answer
Parent/Guardian Name(s) *
(if you are registering as an adult, you can select an non-parental emergency contact below)
Your answer
Parent/Guardian Phone Number(s) *
(if you are registering as an adult, you can select an non-parental emergency contact below)
Your answer
In case of emergency, contact *
Medical Information
Physician Name & Phone Number *
Your answer
Dentist Name & Phone Number *
Your answer
Medical Insurance Company *
Your answer
Group # / ID # *
Your answer
Insurance Address & Phone *
Your answer
First Participant Registration
First Participant's Name *
Your answer
First Participant's Date of Birth *
MM
/
DD
/
YYYY
First Participant's current grade
(if a student)
Date of Last Tetanus shot *
Your answer
List any pre-existing medical conditions or any food or drug allergies that would be pertinent for this trip:
Your answer
List any current medications/dosage:
Your answer
Anything else we should be aware of?
Your answer
Second Participant Registration
Second Participant's Name
Your answer
Second Participant's Date of Birth
MM
/
DD
/
YYYY
Second Participant's current grade
(if a student)
Date of Last Tetanus shot
Your answer
List any pre-existing medical conditions or any food or drug allergies that would be pertinent for this trip:
Your answer
List any current medications/dosage:
Your answer
Anything else we should be aware of?
Your answer
Third Participant Registration
Third Participant's Name
Your answer
Third Participant's Date of Birth
MM
/
DD
/
YYYY
Third Participant's current grade
(if a student)
Date of Last Tetanus shot
Your answer
List any pre-existing medical conditions or any food or drug allergies that would be pertinent for this trip:
Your answer
List any current medications/dosage:
Your answer
Anything else we should be aware of?
Your answer
Fourth Participant Registration
Fourth Participant's Name
Your answer
Fourth Participant's Date of Birth
MM
/
DD
/
YYYY
Fourth Participant's current grade
(if a student)
Date of Last Tetanus shot
Your answer
List any pre-existing medical conditions or any food or drug allergies that would be pertinent for this trip:
Your answer
List any current medications/dosage:
Your answer
Anything else we should be aware of?
Your answer
Trip Specifics
Would you be able to drive your vehicle?
Total # of seats in vehicle
(including driver)
Your answer
Name of friend who invited you.
Your answer
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service