Adult & Family Registration_West Virginia Trip- June 15-22, 2019
Adult and family participants: are not required to make the same financial commitment to the mission trip because of their own travel expenses. Although a monetary donation at any level is encouraged. Checks are payable to “Bethany Church” (note WV Mission Trip on memo).

Checks are payable to “Bethany Church” (note WV Mission Trip on memo).

Registration forms, a $50 deposit, and T-Shirt size by Sunday, May 5, 2019 to receive preference for your placement. Registration will remain open until 6/7.

Questions? Please contact: Dan Cameron at 724-854-3052 or Nate Childers 724-974-9250.

Email address *
ADULT/FAMILY REGISTRATION INFORMATION
First Adult Name (First & Last) *
Your answer
Second Adult Name (First & Last) *
Your answer
Children's Name(s) and Grade (s) *
Your answer
Volunteer Preference
T-Shirt Sizes
Address *
Your answer
Mobile Phone: *
Your answer
Please list any physical or other conditions requiring medication, treatment, or special requirement(s): *
Your answer
Please list any allergies (bee stings, nuts, etc.) or dietary restrictions:
Your answer
Insurance Carrier: *
Your answer
Insurance ID/Policy #
Your answer
Insurance Phone #: *
Your answer
Church Affiliation
Your answer
Emergency Contact Name *
Your answer
Emergency Phone Number *
Your answer
COST
Adult and family participants: are not required to make the same financial commitment to the mission trip because of their own travel expenses. Although a monetary donation at any level is encouraged. Checks are payable to “Bethany Church” (note WV Mission Trip on memo).
TRANSPORTATION
Transportation is provided by a Watson bus on Saturday, Nov. 17 at 7:15 am and Sunday, Nov. 18 at 3:00 pm. Special transportation will be provided on Friday evening for the 5th & 6th grade attending. Please let us know below if you need to drop off late, pick-up early, and what date/time.
LIABILITY RELEASE
I give permission for my child to be transported to and attend West Virginia Trip with Bethany Church. I release Bethany Presbyterian Church, as well as employees and volunteers from any and all claims or liability arising out of this participation. In case of emergency involving my child, I understand every effort will be made to contact me. In the event that I cannot be reached, I allow the adult leader to select a medical provider to secure the proper treatment of my child at my expense. This includes hospital visits, injections, and/or medication.
MEDIA RELEASE
I understand that the image and/or voice of my child may be recorded while attending programs and activities with Bethany Church, Mercer, PA. I give my consent to the use of any type of media recording of my child for any editorial and/or promotional material by Bethany Church and/or partnering organizations while attending said programs and activities.
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