You can always press Enter⏎ to continue
Question Label
1
of
13
See All
Go Back
Submit
church
2019 Summer Mission Trip Registration
In order to complete this registration you will need a copy of your teen's insurance card.
START
church
1
Previous
Next
Submit
Press
Enter
2
*
This field is required
Please attach a copy of BOTH sides of your teen's insurance card to this form.
Drag and drop files here
Select files to upload
Max. file size
: 10.6MB
Browse Files
Cancel
of
Previous
Next
Submit
Press
Enter
3
Participant Information
*
This field is required
Participant First Name
Participant Last Name
DOB
Grade 6
Grade 7
Grade 8
Grade 9
Grade 10
Grade 11
Grade 12
Chaperone
Grade 6
Grade 7
Grade 8
Grade 9
Grade 10
Grade 11
Grade 12
Chaperone
Current Grade
Student Cell Phone
Student Email
School Attending
Small
Medium
Large
Extra Large
XXL
Small
Medium
Large
Extra Large
XXL
T Shirt Size
Previous
Next
Submit
Press
Enter
4
Additional Participant Information
*
This field is required
Hammond, IN June 21-24 (Grades 6-8. Must be 12 years old by June 21st.)
St. Louis, MO July 8-14 (Grades 9-12. Teens 18+ by July 14th will need to be Safe Environment Trained.)
Hammond, IN June 21-24 (Grades 6-8. Must be 12 years old by June 21st.)
St. Louis, MO July 8-14 (Grades 9-12. Teens 18+ by July 14th will need to be Safe Environment Trained.)
Mission Trip Attending: Please note 2018-19 8th graders may choose either mission trip.
Holy Family, Sacred Heart, St. Mary, St. Peter: Holy Family Parish
Our Risen Savior and Presentation Blessed Virigin Mary
Shepherd of the Hills and St. Matthew
Sons of Zebedee and St. Mary
St. Isidore, St. John the Baptist, St. Mary: Holyland Catholic Parishes
Holy Family, Sacred Heart, St. Mary, St. Peter: Holy Family Parish
Our Risen Savior and Presentation Blessed Virigin Mary
Shepherd of the Hills and St. Matthew
Sons of Zebedee and St. Mary
St. Isidore, St. John the Baptist, St. Mary: Holyland Catholic Parishes
Parish
Medical/Behavioral Conditions: Please list all conditions, warning signs, and actions to be taken.
I give permission to
I do not give permission to
I give permission to
I do not give permission to
Transport my child to a hospital for emergency medical treatment or to administer any medication already provided to the parish.
Previous
Next
Submit
Press
Enter
5
Parent Information
*
This field is required
Mother's Name
Mother's Cell Phone
Father's Name
Father's Cell Phone
Parent Email
Confirm Parent Email
Yes, I would like to chaperone, please send me more information.
No thanks, I prefer not to chaperone.
Yes, I would like to chaperone, please send me more information.
No thanks, I prefer not to chaperone.
Chaperoning
Previous
Next
Submit
Press
Enter
6
Mailing Address
*
This field is required
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Previous
Next
Submit
Press
Enter
7
Emergency Contact Information
*
This field is required
If you are unable to reach a parent/guardian at the above numbers, contact:
Alternative Contact Name
Alternative Contact Phone Number
Previous
Next
Submit
Press
Enter
8
Previous
Next
Submit
Press
Enter
9
I understand that a spot will not be saved for my child(ren) until payment has been received. I also understand that once I have submitted a down payment I am obligated to pay the total cost of the trip and help to fundraise for the extra costs.
*
This field is required
Financial assistance is available. Please do not let the cost of the trip stop your teen from participating.
YES, I understand.
NO
Previous
Next
Submit
Press
Enter
10
*
This field is required
By checking the box below you agree to the photo permission and consent and release for all children listed on this form. You should scroll below to fully read the terms & conditions. If you would not like to agree to these terms and conditions please email your youth minister.
Previous
Next
Submit
Press
Enter
11
Parent or Guardian Signature
*
This field is required
Clear
I certify that the above facts are true to the best of my knowledge.
Previous
Next
Submit
Press
Enter
12
A link will be sent to the parent email address for additional registration information needed. This information form is for parish records. More information may need to be sent to each mission company.
Previous
Next
Submit
Press
Enter
13
Tags
[object Object]
Previous
Next
Submit
Press
Enter
Should be Empty: