JUNE 2018 MISSION TRIP INDIVIDUAL REGISTRATION FORM
Please complete this form completely. All questions are required. If you have any questions please contact:

Rev. Evan Dolive
edolive@fcclongview.org
903-753-7611

PRICE: $175
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Participant's Name *
First and Last
Participant's Church *
Participant's Address *
Participant's Phone Number *
Gender *
Grade *
This is the grade you completed in the 2017-2018 Academic School Year; Adults please select "Adult"
Birthday *
MM/DD/YYYY FORMAT
T-Shirt Size *
Parent/Guardian's Name *
Adults please put down an emergency contact
Parent/Guardian Address *
Parent/Guardian Best Phone Number *
Parent/Guardian Email Address *
Emergency Contact #2 *
Emergency Contact #2 Address *
Emergency Contact #2 Best Phone Number *
Insurance Information *
Please put Name of Insurer, Policy or Group Number.
Physician Information *
Please list your primary care physician's name, number and address.
Dietary Restrictions? *
Food Allergies? *
Any allergies/medical conditions/situations that the leaders need to be aware of? (This will remain confidential) *
Do you agree to the following statement? *
Mission & Event Activities may include but are not limited to: painting, climbing ladders, scraping paint, sanding, swimming, sports, water recreation, amusement parks and group games.  By checking the box below I do hereby assume all risks of the above and any other ordinary risk incidental to the mission setting and will hold all officers, planners, hosts and their Trustees, employees, agents, volunteers and sponsors harmless from any and all liability.  I hereby grant permission to use photos of the above named participant, taken during activities during the mission trip, for publicity purposes, including but not limited to advertising material, on web sites, in print, or social media sites.
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