Impact Appalachia (GROUP APPLICATION)

Please fill out his form in it's entirety.

$0

Total
Church/Group Name
Group Leader Name Group Leader Name * First Middle Last
Position/Title with the Church/ Group *
Address Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone Phone - ### - ### ####
Email *
Group Member INFO

Please fill this out in it's entirety:
Total number of participants in your group that you are registering: *
Name, Age, Gender, T-shirt Size (of all members)
Ex: John Doe, 23, Male, XL
Jane Doe, 19, Female, M *
I understand as a group leader, that any team members under the age of 18 must have a legal guardian's permission to attend this trip with Impact PCG Student Ministries. I agree that I will obtain the proper permission for all team members wherein it applies. *

I understand as a group leader, that any team members under the age of 18 must have a legal guardian's permission to attend this trip with Impact PCG Student Ministries. I agree that I will obtain the proper permission for all team members wherein it applies. Yes, I agree No
Are there any current moral issues or physical conditions that could affect anyone's involvement on this Mission Trip? *

Are there any current moral issues or physical conditions that could affect anyone's involvement on this Mission Trip? Yes (if yes, please explain below) No
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 (and all team members listed on this application) picture, voice and/or testimony in any form of promotional materials. My enclosed signature signifies my approval of all limitations listed above.
Team Leaders 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 per person)

(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 (GROUP APPLICATION)

Impact Appalachia (GROUP APPLICATION)

$0

Total

Group Member INFO

Name, Age, Gender, T-shirt Size (of all members)

AUTHORIZATION:

APPLICATION FEE PAYMENT ($50 per person)

$`0`