Mission Trip Registration and Deposit

Student's Complete Name (First, Middle, Last) REQUIRED Please fill out this field. Please enter valid data.

Gender REQUIRED Male Female Please fill out this field.

Date of Birth REQUIRED Please fill out this field. Please enter a date.

What grade is student in? 9th 10th 11th 12th

Address REQUIRED Please fill out this field. Please enter valid data.

City REQUIRED Please fill out this field. Please enter valid data.

State REQUIRED Please fill out this field.

Zip REQUIRED Please fill out this field. Please enter a zip code.

Student's Cell Phone Number REQUIRED Please fill out this field. Please enter a phone number.

Student's Email (Please DO NOT put parent email in this space) REQUIRED Please fill out this field. Please enter an email address.

Student resides with REQUIRED Please fill out this field.

Does Student have a passport? REQUIRED Yes No, but will be applying for one soon. Please fill out this field.

Student's Accommodations (people that desire a room with no roommates are priced higher) 1 room with 2 beds - 2 students in the room 1 room with 2 beds - 1 student, 1 parent in room (has to be student's own parent) 1 room with 1 bed - no roommate

Optional: Student's Roommate Please enter valid data.

Optional: Who will be Student's Chaperone on mission trip? Please enter valid data.

Optional: Chaperone's email Please enter an email address.

Optional: Chaperone's cell phone number Please enter a phone number.