PHILIPPINES MISSION TRIP 2020 APPLICATION
We're excited for your mission trip to start, but first we need some information from you.

Please fill out this form and carefully read all the terms and conditions. Once you complete this form, you can digitally sign it below and submit it.
PERSONAL INFORMATION
First Name *
Your answer
Last Name *
Your answer
Age *
Your answer
Date of birth *
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Address *
Your answer
City *
Your answer
State *
Your answer
Zip *
Your answer
Email *
Your answer
Cell
Your answer
EMERGENCY CONTACT
First Name *
Your answer
Last Name *
Your answer
Relationship *
Your answer
Main Phone *
Your answer
Alternate Phone *
Your answer
Email *
Your answer
MEDICAL PROFILE
List Any Pertinent Medical Conditions *
Your answer
List Any Food or Medicine Allergies *
Your answer
Have you had a tetanus shot in the past 10 years? *
Date of Tetanus Immunization (Must be within last 10 years) *
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Family Physician *
Your answer
Family Physician Phone *
Your answer
Insurance is required for all trip participants. If you do not have coverage, you are expected to purchase temporary health insurance for the trip.
Insurance Company *
Your answer
Insurance Company Address *
Your answer
Insurance Company City *
Your answer
Insurance Company State *
Your answer
Insurance Company Zip *
Your answer
Insurance Company Phone *
Your answer
Policy and Group # *
Your answer
Subscriber Name *
Your answer
Subscriber Phone *
Your answer
PARTICIPANT RESPONSIBILITIES
While serving on a Pleasant Hill SDA Church Youth Mission Trip, I will seek to demonstrate my love for Christ and for others by agreeing to the following:

I agree not to use tobacco products, alcoholic beverages or illegal drugs.

I agree not to engage in or promote the use of obscene language, dangerous behavior, or sexual, illicit or illegal activity.

I agree not to have possession of or use any fireworks, firearms, knives, or other dangerous items.

I agree to abide by the Pleasant Hill SDA Church Mission Trip Dress Code.

I will respect the lights out time, each night.

I agree to stay with the group at all times.

I agree not to go into the room of the opposite sex.

I understand that others' possessions must not be tampered with or taken.

I will do my best to keep all areas of the lodging facility clean.

I am excited to serve the Lord through a week of service.
YOUTH RELEASE OF LIABILITY & ASSUMPTION OF RISK AGREEMENT
In conjunction with the NORTHERN CALIFORNIA CONFERENCE OF SEVENTH-DAY ADVENTISTS ("NCC") and it's affiliated organizations, the Pleasant Hill Seventh-day Adventist Church Youth Ministries (herein after the "PHSDA Youth Ministries") offers a number of interesting and exciting indoor and outdoor activities including, but not limited to, community cleanup, camping, religious meetings, mission trips, boating, hiking, biking, caving, skating, skiing & snowboarding, snorkeling, swimming, fishing, rock climbing, and crafts. While we strive to make each of our activities as safe as possible, many of these activities will still have their own inherent dangers and risks of injury or even death that cannot be completely eliminated even when well-planned and supervised.

When a participant agrees to engage in the PHSDA Youth Ministries activities such as those outlined above or other PHSDA Youth Ministries sponsored activities, it is the responsibility of the participant and, if the participant is under 18, his or her parent or guardian, to know their own physical limitations, learn safe techniques and to learn the proper use and limitations of each piece of equipment, if any, used in such activities. A participant should only agree to participate in an activity after taking the time to become familiar with it and it's associated risks. If you have any questions about a particular activity, it's physical demands, the use of associated equipment or the inherent risks with that activity, PLEASE contact an instructor or supervisor before agreeing to participate.

This certifies that I, as the parent/guardian named below, am aware that participation in the activities offered by the NORTHERN CALIFORNIA CONFERENCE OF SEVENTH-DAY ADVENTISTS ("NCC"), it's affiliated organizations and/or the PHSDA Youth Ministries, has inherent risks of injury and even death. Participation in these activities is voluntary and I consent to participation with the knowledge of the risks involved. In consideration of said participation, I, individually, and/or on behalf of my child, agree to assume the risks of participation, and to release and discharge the NORTHERN CALIFORNIA CONFERENCE OF SEVENTH-DAY ADVENTISTS, it's affiliated organization and/or the PHSDA Youth Ministries, and their employees, offices, directors, members, or agents from any and all claims, demands, actions, judgments, and executions for personal injuries or injuries to property caused by, or the result of participation in an activity offered by NORTHERN CALIFORNIA CONFERENCE OF SEVENTH-DAY ADVENTISTS, it's affiliated organizations, and/or the PHSDA Youth Ministries, unless such injury is the result of the intentional wrongful act or gross negligence of the NORTHERN CALIFORNIA CONFERENCE OF SEVENTH-DAY ADVENTISTS, it's affiliated organizations and/or Pathfinder Club, or their directors, leaders, or members. By signing below, I acknowledge that I have CAREFULLY read, understand and agree to be bound to the above.
PHOTO MEDIA RELEASE
This certifies that I, as the parent/guardian of the child named below, hereby grant permission to the Pleasant Hill Seventh-day Adventist Church, to use materials depicting my child named below (including, but not limited to, slides, video, recordings, sound recordings, photographs, and movie film) which has been, is now, or will be taken, recorded, or produced by said church for the purpose of promotion, news articles, visual aids, website, or otherwise.
PASSPORT
If you do not have a passport. Please make sure to apply for a passport by November 30 and turn in proof of your application to Pastor Miguel or Cheri Cautiverio. Passports must be good for seven months passed the trip date (December 2020).
Do you have a passport? *
If yes, when does it expire?
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PARTICIPANT PARAGRAPH
Please tell us, in a paragraph, why you would like to participate in the Philippines Mission Trip 2020. *
Your answer
SIGNATURES
Please complete and sign the form below. By typing in your name and submitting this form, you agree to all its terms and conditions and grant permission for the participant to participate in the Philippines Mission Trip 2020.
Signature of Participant *
Your answer
Parent Signature *
Your answer
Date *
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