Impact Appalachia (INDIVIDUAL APPLICATION)

Please fill out this form in it's entirety.

$0

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Name (as it appears on birth certificate/passport) Name (as it appears on birth certificate/passport) First Middle Last
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone Phone - ### - ### ####
Email
Date of Birth Date of Birth / MM / DD YYYY
Sex

Sex Male Female
T-Shirt Size

T-Shirt Size S M L XL XXL XXXL XXXXL
GUARDIAN INFO: (only fill this portion out if you are under age 18)

Father/Guardian Info
Name Name First Last
Phone Phone - ### - ### ####
Email
Mother/ Guardian Info
Name Name First Last
Phone Phone - ### - ### ####
Email
TELL US ABOUT YOUR PERSONAL HISTORY
Have you ever been on a mission trip

Have you ever been on a mission trip Yes No
If YES, what country and with whom?
Are you traveling with a group?

Are you traveling with a group? Yes No
If YES, name the group:
TELL US ABOUT YOUR PERSONAL WALK:

(use a separate sheet if needed)
Are there any current moral issues or physical conditions that could affect your involvement on this Mission Trip?
How active are you in ministry at your Church or in another outreach?
Why do you want to serve on this Mission Adventure?
PLEASE PROVIDE THE FOLLOWING INFORMATION FOR A PERSONAL REFERENCE:

(These people must be 21 or older, have known you at least one year, and must not be related to you)
Name Name First Last
Position/Title
Relationship to you
Length of time known
Phone Phone - ### - ### ####
Email
LODGING QUESTION:
We are happy to provide lodging for Saturday night at the host hotel (located in Pulaski, VA) if you would like to stay over. Some groups prefer to head home after the event ends on Saturday (approximately 2 PM).

We are happy to provide lodging for Saturday night at the host hotel (located in Pulaski, VA) if you would like to stay over. Some groups prefer to head home after the event ends on Saturday (approximately 2 PM). YES - Our group will be staying over Saturday Night. NO - We will be headed home after the event.
If you are staying over Saturday Night, we would love to host you at New Hope Church for one of our Sunday morning services if you would like to us to save seats please just indicate the number that would be staying over:
Choose service time

Choose service time 9:15 AM 11 AM
AUTHORIZATION:

I have read and understand the above information. The information I have given Impact Student Ministries is accurate and true to the best of my knowledge. I also give Impact PCG Student Ministries the right to use my picture, voice and/or testimony in any form of promotional materials. My enclosed signature (and signature of my parent or legal guardian because I am under the age of 18) signifies my approval of all limitations listed above.
Applicants Signature

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Date Date / MM / DD YYYY
Parents Signature

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Date Date / MM / DD YYYY
APPLICATION FEE PAYMENT ($50)

(Your non-refundable application fee is required before your application can be processed - your remaining balance will be due by the start of the trip)

Impact Appalachia (INDIVIDUAL APPLICATION)

Impact Appalachia (INDIVIDUAL APPLICATION)

$0

Total

GUARDIAN INFO: (only fill this portion out if you are under age 18)

TELL US ABOUT YOUR PERSONAL HISTORY

TELL US ABOUT YOUR PERSONAL WALK:

PLEASE PROVIDE THE FOLLOWING INFORMATION FOR A PERSONAL REFERENCE:

LODGING QUESTION:

AUTHORIZATION:

APPLICATION FEE PAYMENT ($50)

$`0`