Chadash Christian Ministries
Wilderness Trip Registration Form for Young Ladies
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Email *
Trip applying for: *
Name: *
Age: *
Date of Birth: *
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/
DD
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Address: *
Phone: *
Email: *
Parent's Names: *
Name of Church You Presently Attend: *
Pastor: *
Pastor's Phone Number: *
Trusted Person in Your Life: *
Phone Number for Trusted Person: *
What would you life to learn/experience on this trip? *
Do you have asthma? *
Do you have diabetes? *
Do you have epilepsy? *
Do you have a heart condition? *
Do you have any dietary restrictions? *
Do you have any allergies? *
Are you currently taking any medications? *
Do you have any disabilities? *
Do you have any phobias or fears? *
Have you had any past surgeries or injuries? *
Are there any vitamins or supplements you take?  If yes, for what reason? *
Do you have any other medical conditions? *
Have you had struggles with eating disorders? *
Do you have any current or past addictions? *
Have you had a history of using drugs? *
Have you ever taken medication for or been diagnosed with a mental health issue? *
Do you have trouble sleeping? *
Height *
Weight *
Emergency Contact Name #1: *
Relationship: *
Phone Number: *
Emergency Contact Name #2: *
Relationship: *
Phone Number: *
How will you be paying the non-refundable application fee of $250? Additional details will be sent in follow-up email. *
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