SM Summer Missions Application

Student Permission/ Medical Release Form
Name

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Grade
City
Home Phone

Area Code Phone Number
Cell Phone

Area Code Phone Number
My signature(s) below will certify that the student named on this form has my permission to participate in Summer Missions Opportunities (SMO) 2023 with ACAC Student Ministries.
My signature(s) below will certify that the student named on this form is in good health and fully able to participate in Summer Missions Opportunities (SMO) 2023 with ACAC Student Ministries.
My signature(s) below will indicate that we will update the ACAC Student Ministries office if there are any changes in emergency contact(s) or medical conditions from one event to another.
ACAC Student Ministries will make every effort to provide safe conditions with adequate adult supervision. We are always interested in providing a safe event in every way and in the spiritual, physical, and mental development of your student(s To help us do so, please complete the following information. Please list any special food limitations that will require a special diet.
Please list any medical allergies or conditions that may be relevant to a physician in the event of an emergency
Please list medication(s) being taken by your student? Please include anti depression or other behavioral medications.
Please list any medical concerns or limitations that our staff should be aware of?
Medical Insurance Company
Group/Policy #
Medical Prescription Policy#
Check if you do not have health
Date of student's last tetanus shot

Month Day Year
Date
In the event of an emergency, please give the name of an Authorized/Designated Individual to make emergency decisions:
Name

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home Phone Number

Area Code Phone Number
Cell Phone Number

Area Code Phone Number
My signature indicates that, in the event of an emergency and in the event that (1) a parent/legal guardian or the Authorized/Designated Individual identified above cannot be reached; or (2) immediate medical attention is necessary, consent to have the Allegheny Center Alliance Church staff/leaders act in my behalf and I hereby grant my permission for emergency treatment to be administered until a parent/legal guardian or Authorized/Designated Individual identified above can be reached. I agree not to hold Allegheny Center Alliance Church, or any staff/leaders, liable for decisions or any emergency medical treatment made under this authorization, for any accident or loss to the student however caused. My signature indicates that have read, and do agree to the conditions listed above, and that have included any necessary information regarding my student(s
Printed name of Parent/Legal Guardian
Signature of Parent/Legal Guardian

Clear
Relationship
Parent Work Number

Area Code Phone Number
Parent Cell Number

Area Code Phone Number
Date

Month Day Year
Date

Mission Trip Application
Name

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Cell Phone Number

Area Code Phone Number
Email
example@example.com
Age
Birthdate

Month Day Year
Date
Grade
School
T-Shirt Size
Family Information
Parent 1 Name
Mother, Father, Parent/Guardian
Parent 1 Email
example@example.com
Parent 1 Phone Number

Area Code Phone Number
Parent 2 Name
Mother, Father, Parent/Guardian
Email
example@example.com
Parent 2 Phone Number

Area Code Phone Number
Mission/Ministry Experience
Please list any previous summer trips you have attended with ACAC
Are you considering full time ministry or missionary service?
Do you sing and/or play an instrument
Would you be willing to do special music on the trip?
Please list any special skills, abilities, or interests you think would be helpful on this mission trip: (e.g., puppets, drama, guitar, dance, sports, musical, children's ministry, media, carpentry, etc.)

Personal Testimony
Please write when and how you became a follower of Christ. This would include what some of the important things were that helped you make the decision.
Each of us has different habits when it comes to devotions or "quiet times" with God. Please share your current habits of spending time with God through prayer and time in His Word.
Please write a little about some of the things you are learning about yourself and your relationship to Jesus either during devotions, at youth group, growth group, church, or wherever you encounter God on a regular basis.
There are many great reasons to go on a summer missions experience - please list your top 2:
1.
2.
Please list 3 hopes or expectations you have for this mission experience.
1.
2.
3.

Student & Parent Financial Memo
student & Parent Financial Memo

By signing this application, I understand that I (and my parents) am responsible for my deposit and inevitably the full cost of my trip. The money I raise covers, travel cost, food, lodging, ministry expenses and designated activities. I am responsible for my passport and the immunizations necessary for my particular mission opportunity. Any souvenirs purchased areat my cost. I understand that the amount of my participation in fundraising will affect my overall portion of the proceeds raised. At the end of fundraising, if the money raised is not enough to cover the trip, I will be responsible for paying the difference.

If, for some reason, I do not ultimately participate on the mission trip to which I have been accepted, I am responsible for any fees incurred as a result of my cancellation.

If I do not raise enough money to pay for my trip, I may not be able to go. Any money raised will be applied to the current trip or materials needed.
Student Signature

Clear
Date

Month Day Year
Date
By signing this application I (the parent) understand that my family is responsible to support my child monetarily, physically, spiritually, and emotionally. I promise to help my son/daughter in raising the funds and trip preparations. I understand that we are responsible to cover the cost of the trip if the funds are not fully raised by fundraisers.

I promise to help keep track of times and dates to insure that my child is on time to meetings and events. I will do everything in my power to keep the leadership of the trip appraised of any conflicts or issues. I understand that my child may be asked to give up their spot on the trip if we fail to meet the minimum requirements.

Finally, I understand that my participation and encouragement is vital to the overall group mentality. I agree to support my child and the mission group in this mission trip in every way that I can.
Parent Signature(s)

Clear
Date

Month Day Year
Date
Date

Month Day Year
Date

Mission Trip Covenant
- I recognize and accept the following conditions for our short-term mission experience. If accepted as a member of this ACAC Mission team, I understand and
- I promise to fully participate in all meetings, scheduled trainings, community building dates, and other special gatherings as listed on the trip details page. Missing any scheduled dates must be pre-approved by my trip leader. If I fail to meet these requirements, I understand that I may be asked to give my spot to another participant who can cover the requirements.
- I will make every effort to be an example of Christ before others with my attitude, actions, speech and social media interactions. I will maintain a positive attitude during all meetings and events leading up to and during the trip.
- I agree to participate regularly in weekend worship services with Student Ministries, ACAC adult church, or my home church. If my home church is other than ACAC, then I must regularly participate in other SM ministries (BLAST, IGNITE, Small Groups, etc)
- I agree to participate in and complete any devotionals to be distributed at a later date.
- I will respect, obey and follow the direction of the trip leaders and other authorities at all times - leading up to and during the trip.
- I will adhere to any dress codes established for activities and during the trip. I understand that dress codes vary depending on the local culture and what is considered appropriate.
- I will lay aside expectations of American standards regarding personal conveniences, food, sleeping accommodations, dress, travel, media, etc. Serving Christ in a foreign environment will require living outside of our cultural norms.
- I will abstain from making derogatory comments or arguments regarding people, polities, sports, religion, race, or traditions while on the mission trip.
- I understand that housing may be cramped and uncomfortable; the environment may be difficult, food may be different and limited, and the schedule tiring.
- I understand that if I do not follow the above commitments that Student Ministry Leadership may choose to disqualify me from participation thereby forfeiting my deposit.
Print Name
Signature

Clear
Date

Month Day Year
Date
Should be Empty:

Student Permission/ Medical Release Form

Mission Trip Application

Family Information

Mission/Ministry Experience

Personal Testimony

Student & Parent Financial Memo

Mission Trip Covenant