Youth Mission Trip

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Student Name

Student Phone

Student Address

Parent Email

This address will receive a confirmation email

Parent/Guardian #1 Name (first/last)and Phone number

Parent/Guardian #2 Name (first,last) and Phone Number

Payment $0.00

Health Insurance

Please select all that apply.

I have medical health insurance I do not have medical health insurance

Student Age

Please select one option.

13 14 15 16 17 18

Student Grade

Please select one option.

6th 7th 8th 9th 10th 11th 12th

Student T Shirt Size

Please select one option.

Youth med Youth Lg Youth XL Adult xsmall Adult small Adult med Adult large Adult Xlg Adult 2x Adult 3x

Does the student have any food allergies?

Is the student allergic to outdoor things like nature, grass, or bugs such as a bee allergy?

Please share any medications student needs administered, and schedule of administration

Has the student been on a mission trip before?

Please select one option.

This is my first mission trip Yes I have been on a mission trip previously

Has the student ever stayed overnight away from home? How do you think your student will handle being a few hours away from family?

I, the parent, give permission for my student to go on the mission trip

Please select one option.

The student has my permission to go on the mission trip.

There is a cost for this trip but there are some scholarships available to help cover. The trip cost is $550, but we have scholarships and fundraising to cover most of the cost. I would plan on trying to save $100 by July 18th.

Thank you for filling out this interest form. There will be official registration from Praying Pelican Missions sent to parent email soon. As soon as your receive that email, please complete it so we can get officially registered.

Credit/Debit Card Number

Expiration Date/CVC

Name on Card

Card Billing Address

Description

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Youth Mission Trip

Description

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