2010 Youth Missions Application

Form to formally apply for the 2010 summer mission trips. Application is due by Sunday, February 28, 2010 with a $50 deposit. Application will be null and void if deposit isn't received by March 31, 2010. The Contact Info in the next session is for the student applicant.

Personal Bio, Covenant, and Release for 2010 Missions Trip
(Personal_bio-_covenant-_and_release-_2010.rtf - 58 KB)
Document to fill out brief biographical information, a statement of your personal covenant regarding mission trips, and an Autumn Ridge Church parental release form.

Contact Information * required

First Name *

Last Name *

Contact Phone *

Mobile Phone

Street *

City *

State *

Postal Code *

For which trip are you applying? *

Alabama Dominican Republic

Name as it appears on your birth certificate or passport *

Do you have a CURRENT passport *

When does your passport expire *

Father's Name: *

Enter N/A if not applicable

Mother's Name: *

Enter N/A if not applicable

Please provide a parent's work phone number *

Please provide a parent's e-mail address *

Enter N/A if not applicable

What is your birthdate *

School Name *

Enter Home School if applicable

What grade are you *

T-shirt Size *

Adult sizes

Small Medium Large X-Large 2X-Large

Emergency Contact #1 *

The next four questions (including this question) are for your FIRST emergency contact

Emergency Contact #2 *

The next four questions (including this question) are for your SECOND emergency contact

Do you regularly attend services at Autumn Ridge Church *

If you normally attend services at a different church, please enter its name in the next question

Yes No I attend at a different church

If you attend services at another church, what church

leave blank if you attend ARC

What ministries are you presently involved with *

Medical Information *

Describe any medical condition that might affect you during the trip (asthma, diabetes, special diet, medication, etc.)

Prescription Medications *

Are you on any prescription medication(s) that you are taking under a doctor's care? Describe in detail.

Allergies *

Please list any known allergies and the reactions to them

Do you have medical insurance *

Yes No Don't Know

Name of health insurance company *

Enter N/A if not applicable

Health insurance policy number *

Enter N/A if not applicable

Name policy is under *

Enter N/A if not applicable

Is policy applicable outside of the U.S. *

Yes No Don't Know N/A

REFERENCES: Adult/Teacher *

Adult/Teacher phone number *

REFERENCES: Adult/Teacher *

Adult/Teacher phone number *

I wish to make the $50 deposit for the mission trip *

If we don't receive your deposit before March 31, 2010, your application will be voided and your space made available for someone else.

I'll pay by credit/debit card [Add $50.00]
I'll bring a check into ARC
I'll pay at a later date

2010 Youth Missions Application

Contact Information * required

For which trip are you applying? *

Name as it appears on your birth certificate or passport *

Do you have a CURRENT passport *

When does your passport expire *

Father's Name: *

Mother's Name: *

Please provide a parent's work phone number *

Please provide a parent's e-mail address *

What is your birthdate *

School Name *

What grade are you *

T-shirt Size *

Emergency Contact #1 *

#1 Work Number *

#1 Home Number *

#1 Cell Number *

Emergency Contact #2 *

#2 Work Number *

#2 Home Number *

#2 Cell Number *

Do you regularly attend services at Autumn Ridge Church *

If you attend services at another church, what church

What ministries are you presently involved with *

Medical Information *

Prescription Medications *

Allergies *

Blood Type

Do you have medical insurance *

Name of health insurance company *

Health insurance policy number *

Name policy is under *

Is policy applicable outside of the U.S. *

REFERENCES: Adult/Teacher *

Adult/Teacher phone number *

REFERENCES: Adult/Teacher *

Adult/Teacher phone number *

I wish to make the $50 deposit for the mission trip *

Total

Pay With
TOTAL	$ 0.00