Mission Trip 2018 Mission Trip information July 12th-16th $150 Total Registration Cost $75 Deposit by January 31st $75 Due by April 30th Registration Deadline January 31st Step 1 of 3 33% Mission Trip Participant InformationParticipant's Name* First Last Participant's Email* Participant's Church*First Presbyterian Church in Spirit LakeFirst Presbyterian Church in Lake ParkParticipant's Phone Number*For communication during the trip.Participant's Gender*MaleFemaleParticipant's Date of Birth* Participant's T-Shirt Size*SmallMediumLargeX-LargeXX-Large(Adult Sizes)Participant's Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Parent/Guardian InformationParent/Guardian's Name* First Last Relation to Participant*Parent/Guardian's Email* Parent/Guardian's Phone*Does the participant have another parent/guardian?* Yes No Other Parent/Guardian's Name First Last Relation to ParticipantOther Parent/Guardian's Email Other Parent/Guardian's Phone Critical Medical / Health InformationDoes your student have any allergies, prescription medications, mental or physical health issues that may impact their experience on the trip?* Yes No Due to HIPAA compliance laws, we will not collect sensitive medical information on the internet registration form. You may download the required medical information registration sheet or it will automatically be emailed to you upon successful completion of this registration form.Primary Care Physician InformationPrimary Care Physician's Name*Primary Care Physician is Located in*(City & State)Health Insurance Insurer*Health Insurance Policy Number Emergency Medical Authorization & WaiversShould it be necessary for my child to have emergency medical treatment while participating in this trip, I hereby authorize First Presbyterian Churches of Spirit Lake, Lake Park, and Estherville, Iowa personnel to use their judgment in obtaining emergency medical services for my child. I further authorize any individual selected by these churches' personnel to render such emergency medical treatment to my child as he/she may deem necessary and appropriate including but not limited to medical assistance, assessment, and surgery or life saving measures if needed. I understand that the First Presbyterian Churches of Spirit Lake and Lake Park, Iowa has no church insurance which pays the medical or hospital costs that might be incurred on behalf of my child. Consequently, I understand that any and all such costs will be my sole responsibility.By signing below I understand that photos, video interviews, and electronic images of my student might be used for the church's promotion, education and future publication. By signing below I acknowledge that I release the First Presbyterian Churches of Spirit Lake and Lake Park, IA from liability and legal action stemming from my own actions, or my child’s behavior, injury and/or activity during the event.I acknowledge that I have read, understand and have signed this form in preparation to attend and participate in the 2018 Summer Mission Trip. By signing I also give my permission for my child / minor charge to be given medical treatment, medical assistance, assessment and surgery or life saving measures if needed: By submitting this application, I certify that I have read the Sent by Love Community Guidelines and Covenant, understand them and indicate that I will live, in community, with fellow Summer Mission trip participants, leaders, and staff by following the guidelines as they are presented. I understand that if I break the covenant or am unable to follow the guidelines I can be sent home, at my own expense. Digital Signature of Parent/Guardian* First Last NameThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.