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Immersion Trip Application
July 20-23, 2022 - CenterPointe Christian Church - Appalachia
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Email
*
Your email
I accept that the trip payment is a non-refundable charitable donation.
*
YES
Required
First Name
*
Your answer
Last Name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Street Address
*
Your answer
City
*
Your answer
State
*
Your answer
Zip code
*
Your answer
Preferred Phone
*
Your answer
Instagram
Your answer
Gender
*
Female
Male
Other:
T-shirt Size (Adult size)
*
S
M
L
XL
XXL
3XL
T-shirt Color
*
Pink
Navy Blue
Gray
Employer (For minors: list parent's employer)
Your answer
Does employer participate in gift or volunteer matching?
Yes
No
Unsure
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Food and/or Drug Allergies *We cannot accommodate specific dietary restrictions. Please bring your own foods to supplement what we offer.
Your answer
Diabetic
*
Yes
No
Vegetarian
*
Yes
No
Physical limitations, health problems that could affect your participation in this trip experience.
Your answer
Emergency Contact Name
*
Your answer
Emergency Contact Relationship
*
Your answer
Emergency Contact Phone Number
*
Your answer
General Liability Waiver and Release
Type full name for acceptance of conditions. Parental name required for minor.
*
Your answer
Safety Guidelines and Code of Ethics
A copy of your responses will be emailed to the address you provided.
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