Youth Mission Trip 2018
Puerto Rico
Student First Name *
Your answer
Student Last Name *
Your answer
Student's Grade
Student Date of Birth *
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Student Email *
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Student Cell Number *
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Have you participated in a mission trip before? *
What skills would you bring on this mission trip for relief work in Puerto Rico? *
Required
Parent/Guardian #1 Full Name *
Your answer
Parent/Guardian #1 Cell Number *
Your answer
Parent/Guardian #1 Email *
Your answer
Parent/Guardian #2 Full Name
Your answer
Parent/Guardian #2 Cell Number
Your answer
Parent/Guardian #2 Email
Your answer
What is the name, cell number, and relation of your emergency contact? *
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Student allergies or medical conditions we should be aware of (if none, please indicate.) *
Your answer
As a parent or guardian of the child(ren) whose name(s) appear(s) above, I hereby give my consent for said child(ren) to participate in St. Pauls United Church of Christ Summer Mission Trip to Puerto Rico in June. I understand that insurance of any kind will not be provided by St. Pauls United Church of Christ for accidents or injuries that may occur, from any cause whatsoever, in connection with the Summer Mission Trip. I agree to relieve from any responsibilities, and to hold harmless, St. Pauls United Church of Christ, its employees, and any other supervisors of the Summer Mission Trip whatsoever that may occur in connection with said activities. *
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