What Church, Organization, or Group will you be attending with?
*
please have your trip coordinator contact us to schedule a trip first.
PERSONAL INFORMATION
At the time of your trip, will you be over the age of 18?(Required)
*
Yes
No
Date of Birth
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Participant Name
*
First Name
Last Name
Phone Number
*
If you do not have a phone number simply put (111) 111 -1111
Email (Required)
*
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Gender(Required)
*
Male
Female
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MEDICAL INFORMATION
Emergency Contact
First Name
Last Name
Emergency Contact Phone #
Please enter a valid phone number.
Relationship
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
List any medical conditions/allergies we should be aware of:
List any medications you are taking:
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PARENT OR GUARDIAN INFORMATION
Parent or Guardian Full Name
First Name
Last Name
Parent or Guardian Email
*This email MUST be different from the minor participant email.
Parent or Guardian Phone Number
Please enter a valid phone number.
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PHOTOGRAPHY AND VIDEO RELEASE FORM
I hereby grant Dream Center of Philadelphia permission to the rights of my image, likeness, and sound of my voice as recorded digitally or on audio or videotape without payment or any other consideration. I understand that my image may be edited, copied, exhibited, published, or distributed and waive the right to inspect or approve the finished product wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of my image or recording.
I agree that Dream Center of Philadelphia may use such images of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and web content. There is no time limit on the validity of this release nor is there any geographic limitation on where these materials may be distributed. I acknowledge that I have completely read and fully understand the above release and agree to be bound thereby. I hereby release, defend, hold harmless, and indemnify Dream Center of Philadelphia from any and all claims for utilizing this material.
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