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Wrightsville PA
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Camp Information
Participant Form
Camp Type:
Group Workcamps
Camp ID:
18PA01
Camp Location:
Wrightsville PA
Camp Date:
Jun 17, 2018
(Please ensure the above information is correct. If you are under 18, your parent / guardian needs to fill this out.)
Personal Information
FIRST NAME
LAST NAME
DATE OF BIRTH
Gender
Male
Female
Will you be driving for this camp?
Yes
No
Communication
EMAIL
CELL PHONE
ADDRESS
CITY
STATE
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ZIP
Emails may be sent to individuals over age 18 for direct communication and marketing of appropriate products and services of Group Mission Trips and related affiliates
Grade
GRADE ENTERING (FALL OF 2018)
6
7
8
9
10
11
12
College
Adult
NUMBER OF GROUP CAMPS ATTENDED
Select
First time
One
Two
Three
4 or more
Criminal History
Note: any of the following that have a ‘Yes’ answer require an explanation.
Sexual misconduct of any kind involving children, youth, or adults, including crimes resulting in a conviction?
Yes
No
Violence against another person resulting in a felony conviction within the last 10 years?
Yes
No
Use, or distribution, of illicit drugs or controlled substances resulting in a conviction in the last 10 years?
Yes
No
Property crime resulting in a conviction in the last 10 years?
Yes
No
Any other characteristics which would render person a threat to others?
Yes
No
ENTER EXPLANATION
WorkCamp Skill Profile
Carpentry
No experience
Some experience
I can cut & nail boards
I can build a new porch
I am a professional
Drywall
No experience
Some experience
I can patch a hole
I can hang new drywall
I am a professional
Painting
No experience
Some experience
I can prepare & paint a house
I can supervise house painting
I am a professional
Roofing
No experience
Some experience
I can patch a new roof
I can install an entire roof
I am a professional
Agreement
My child and I have seen, read, and agree to every aspect of the
Liability and Release Agreement
and the
Code of Conduct
. By signing this form, I hereby authorize Group Mission Trips to use or disclose my child’s protected health information for the purposes of treatment, payment, health care operations, or any other disclosures as allowed by law in connection with any accident, medical incident, or claim made. (Please note: as a participant, you are responsible for your own health insurance needs and are advised to bring your personal health insurance information with you on your mission trip.)
I have seen, read, and agree to every aspect of the
Liability and Release Agreement
and the
Code of Conduct
. By signing this form, I hereby authorize Group Mission Trips to use or disclose my protected health information for the purposes of treatment, payment, health care operations, or any other disclosures as allowed by law in connection with any accident, medical incident, or claim made. (Please note: as a participant, you are responsible for your own health insurance needs and are advised to bring your personal health insurance information with you on your mission trip.)
I understand by typing my full legal name below that I am authorizing my digital signature as my legally binding signature.
FIRST AND LAST NAME OF PERSON 18+
Signed On
Apr 23, 2018
FIRST NAME
LAST NAME
EMAIL
PRIMARY PHONE
SECONDARY PHONE
ADDRESS
CITY
STATE
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Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Ontario
New Brunswick
British Columbia
Virgin Islands
DC
Manitoba
Tokyo
ZIP
Emails may be sent for direct communication and marketing of appropriate products and services of Group Mission Trips and related affiliates
INSURANCE COMPANY
INSURANCE NUMBER
VEHICLE TYPE
Car
Van
Bus
Truck
SEATS AVAILABLE (including the driver)