Mission Trip Application

Personal Information:

Name

This address will receive a confirmation email

Phone

Address

Please list any allergies or dietary restrictions:

Is there anything else you would like us to be aware of that may impact your ability to participate during trip activities?

Please share with us why would you like to be a part of this Mission Trip.

I agree to attend the required training meetings prior to the trip, held on April 16, May 21, June 11, from 6:00 – 8:00 pm at WPC.

Emergency Contact Information

Name

Phone

Second phone number

Waiver:

I, (or the undersigned parent/guardian of the participant named above if under 18 years of age), authorize the calling of a doctor and the providing of necessary medical services in the event of injury or illness. I authorize one or more of the following persons to make emergency medical care decisions on my (or on behalf of the participant under 18), if required by law or a health care provider: Trip leaders Anna Hadorn or Marjorie Burdette, or another adult designated by either of these two. I authorize these persons to act in my place to consent to all necessary and appropriate x-ray examinations, anesthetic, medical or surgical diagnosis or treatment, and hospital care. I understand that the staff and volunteers of WPC will not be responsible for medical expenses incurred on the basis of this authorization. I further agree to notify the NextGen Director in writing of any health changes that would restrict participation in any mission trip activities. I also understand that the NextGen Director and volunteer youth leaders reserve the right to restrict participation from any activity that they do not feel is within the physical capabilities participants.

I understand that photo/video may be taken on the trip and accept that that this media may be posted to WPC's website or social media platforms.

Deposit:

Please pay a $100 deposit to reserve your spot on the trip! You can pay online (a $3 processing fee is included) or give Anna Hadorn a cash or chack payment.

Registration Deposit

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

Description

This trip is taking place Sunday, July 9 - Friday, July 14. The total cost of the trip is $450 per person. Please reach out to Anna Hadorn or Marjorie Berdette with any questions.

Mission Trip Application

Description

Please Fix the Following