Youth Mission Trip Registration

Name *

First

Last

Grade *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Student Phone Number *

Parent Phone Number *

Student Email *

Parent Email *

Registration is not complete until a deposit check of $50 is received by the church office.
Deadline for the deposit is February 21, 2010.
A Permanent Medical Release Form must be on file with the church prior to the trip.