Please complete this form completely. All questions are required. If you have any questions please contact:

Rev. Evan M. Dolive

PRICE: $175

Participant's Name *
First and Last
Your answer
Participant's Church *
Participant's Address *
Your answer
Participant's Phone Number *
Your answer
Gender *
Grade *
This is the grade you completed in the 2018-2019 Academic School Year; Adults please select "Adult"
Birthday *
Your answer
T-Shirt Size *
Parent/Guardian's Name *
Adults please put down an emergency contact
Your answer
Parent/Guardian Address *
Your answer
Parent/Guardian Best Phone Number *
Your answer
Parent/Guardian Email Address *
Your answer
Emergency Contact #2 *
Your answer
Emergency Contact #2 Address *
Your answer
Emergency Contact #2 Best Phone Number *
Your answer
Insurance Information *
Please put Name of Insurer, Policy or Group Number.
Your answer
Physician Information *
Please list your primary care physician's name, number and address.
Your answer
Dietary Restrictions? *
Food Allergies? *
Any allergies/medical conditions/situations that the leaders need to be aware of? (This will remain confidential) *
Your answer
Do you agree to the following statement? *
Mission & Event Activities may include but are not limited to: painting, climbing ladders, scraping paint, sanding, swimming, sports, water recreation, amusement parks and group games. By checking the box below I do hereby assume all risks of the above and any other ordinary risk incidental to the mission setting and will hold all officers, planners, hosts and their Trustees, employees, agents, volunteers and sponsors harmless from any and all liability. I hereby grant permission to use photos of the above named participant, taken during activities during the mission trip, for publicity purposes, including but not limited to advertising material, on web sites, in print, or social media sites.
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