Missions Trip Registration Form- (Deadline November 12, 2023)

Personal Info

Name

This address will receive a confirmation email

Address

Phone

Birthdate

Gender

Marital Status

Spouses Name (if applicable)

Spiritual Info

Do you faithfully attend Edgewood Assembly of God

Please briefly describe your salvation experience of when you gave your life to God.

Please briefly describe why you hope to go on this missions trip.

Medical Info

Please list any/all allergies or health issues that may exist

Please lis any /all medications taken regularly

Family Doctor

Family Doctor's phone #

Please attach a copy of your health insurance card (or bring to the church office in person)

Upload (8MB)

Emergency Contact

Emergency Contact's Name

Emergency Contact's Relationship to you

Emergency Contact's Address

Emergency Contact's Home Phone # (if applicable)

Emergency Contact's Work # (if applicable)

Emergency Contact's Mobile Phone #

Consent & Hold Harmless Statement

I/We the undersigned representing myself, have given my consent to participate in the aforementioned events with Edgewood Assembly of God. I understand that there are inherent risks involved in any ministry or event, and I release the Church, its pastors, employees, agents, and volunteer workers from any and all liability for injury, loss, or damage to person or property that may occur during the course of my involvement. I also acknowledge that photographs may be taken at such events and may be used for promotional purposes including, but not limited to, fliers, banners, and the church website. In the event that I am injured, I consent to reasonable medical treatment as deemed necessary by a licensed physician. In the event treatment is required from a physician and/or hospital personnel designated by the Church, I agree to hold Edgewood Assembly, as well as, such person free and harmless of any claims, demands, or suits for damages arising from the giving of such consent. I also acknowledge that I will be ultimately responsible for the cost of any medical care should the cost of that medical care not be reimbursed by the health insurance provider. Further I affirm that the health insurance information previously provided, and on file is accurate at this date and will, to the best of my knowledge, still be in force for myself/student named above. I also agree to travel home/bring my child home at my own expense should I/they become ill, or if deemed necessary by the Church staff.

Please prepare for the trip by praying! You will also be contacted soon with further details about the trip. Thanks!

Payment $50 (Trip Registrationdeposit)

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

Missions Trip Registration Form- (Deadline November 12, 2023)

Description

Please Fix the Following