Group Mission Trips Form

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

Communication

CELL PHONE

ADDRESS

CITY

STATE

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)

College

Adult

NUMBER OF GROUP CAMPS ATTENDED

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

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

PRIMARY PHONE

SECONDARY PHONE

ADDRESS

CITY

STATE

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)