Appalachian Mission Trip 2018 - Application
First Name *
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Last Name *
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Cell Phone *
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Email *
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Date of Birth *
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Major *
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Year in School *
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Emergency Contact *
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Emergency Contact's Relationship to You *
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Emergency Contact's Phone Number(s) *
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Medical Insurance Provider *
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Insurance ID Number *
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Doctor *
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Doctor's Phone Number *
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List of dietary needs, allergies, medications, or other pertinent comments. *
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I agree to the rules and expectations for participating in an Alternative Spring Break trip through St. Francis of Assisi Newman Center. I will be committed to preparation meetings, contributing queal effort to fundraising and to fully participating on the trip. I understand that if I fail to fulfill this commitment, my participation in the experience could be terminated, possibly at my own expense. *
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