IMPACT APPALACHIA GROUP REGISTRATION FORM

$275* (pre-reg price) /$285 per person (Late registration after November 1st; Non-refundable)
*Special group rate: For Groups of 10 or more who register on or before November 1st - $250 per person.

*November 1st: Application and $50 down payment in order to get the pre-reg price. All applicants after Nov. 1st will pay $285, *any registrations submitted after 11:59 pm (CT) November 1st will be subject to the late registration price.

-WE WILL COLLECT A $50 DEPOSIT WITH APPLICATION & REMAINING BALANCE IS DUE AT THE DOOR-

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GROUP NAME
GROUP LEADER NAME GROUP LEADER NAME First Last
GROUP LEADER EMAIL
GROUP LEADER PHONE GROUP LEADER PHONE - ### - ### ####
PLEASE LIST THE TOTAL NUMBER COMING IN YOUR GROUP
T-SHIRT SIZES (PLEASE INDICATE IF IT IS A YOUTH SIZE)
WILL YOUR GROUP BE STAYING AT THE HOST SITE (PULASKI, VA) HOTEL ON SATURDAY NIGHT? *FYI - SITE PROGRAMS TYPICALLY END BETWEEN 1PM - 2PM ON SATURDAY

WILL YOUR GROUP BE STAYING AT THE HOST SITE (PULASKI, VA) HOTEL ON SATURDAY NIGHT? *FYI - SITE PROGRAMS TYPICALLY END BETWEEN 1PM - 2PM ON SATURDAY YES NO WE WILL LEAVE RIGHT AFTER THE EVENT ON SATURDAY TO HEAD HOME
PASTORAL/GROUP LEADER APPROVAL
DO YOU HAVE ANY HESITATIONS ABOUT ANY OF YOUR TEAM MEMBERS ATTENDING AND SERVING ON THIS MISSION TRIP?

DO YOU HAVE ANY HESITATIONS ABOUT ANY OF YOUR TEAM MEMBERS ATTENDING AND SERVING ON THIS MISSION TRIP? YES NO
UNDERSTANDING THAT MY GROUP WILL BE HOUSED TOGETHER AT THE HOST HOTEL, I UNDERSTAND AND ACKNOWLEDGE THAT I AM RESPONSIBLE FOR MY GROUP AT THE HOST HOTELS & ON THE TRIP.

(GROUP LEADER WILL BE ABLE TO ASSIGN HOTEL HOUSING - COORDINATING WITH IMPACT TEAM REPRESENTATIVE)

UNDERSTANDING THAT MY GROUP WILL BE HOUSED TOGETHER AT THE HOST HOTEL, I UNDERSTAND AND ACKNOWLEDGE THAT I AM RESPONSIBLE FOR MY GROUP AT THE HOST HOTELS & ON THE TRIP.

(GROUP LEADER WILL BE ABLE TO ASSIGN HOTEL HOUSING - COORDINATING WITH IMPACT TEAM REPRESENTATIVE) YES I UNDERSTAND AND TAKE RESPONSIBILITY FOR MY GROUP
Draw your signature into the box below.

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.

IMPACT APPALACHIA GROUP REGISTRATION FORM

IMPACT APPALACHIA GROUP REGISTRATION FORM

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PASTORAL/GROUP LEADER APPROVAL

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