Name *

First Name

Last Name

Phone

(###)

###

####

Mailing Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Birthdate *

MM

DD

YYYY

Parent or Legal Guardian's Name

N/A for Adults

First Name

Last Name

Parent or Legal Guardian's Phone

(###)

###

####

Church's Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Areas of Interest

Please check all that apply. Our staff will do the best of our ability to place you on a team to serve in this capacity.

Children's Ministry

Eyeglass Clinic

Festival Site/Production

Medical Team

Physical Labor/Practical Work

School Ministry

Sports Outreaches

Street Evangelism

Medical Insurance Phone Number:

(###)

###

####

Contact in Case of Emergency Medical Treatment: *

First Name

Last Name

Emergency Contact Phone Number: *

(###)

###

####

Do you agree to the assumption of risk?

Yes, I do

No, I do not