Clone of Vinton Baptist DNow Weekend

Vinton Baptist Passport Mission Trip

June 21-26 at the University of Richmond
Participants Details
Student Name:*

First NameLast Name
Student Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent Name:*

First NameLast Name
Parent Phone:*
Please enter a valid phone number.Format: (000) 000-0000.
Parent Email:*
example@example.com
T-shirt Size*
*Adult sizes only*
I'm coming as a friend! My friend is:
Student's Date of Birth*

MonthDayYear
Date
CashCheck (made out to Vinton Baptist Church)Online (vintonbaptistchurch.org/give)Scholarship Assistance Needed
$125 deposit due on April 20th

$300 final payment due on May 5th

If paying online, please go to: Vintonbaptistchurch.org/give

-Select One Time gift

-Youth Summer Trip

-Please include your student's name in the memo line

Emergency Contact
Emergency Contact Name*

First NameLast Name
Phone Number*
Relationship to Participant*
Emergency Contact 2
Emergency Contact Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Participant

Medical Details
Doctor Name*
Doctor Address, City, State, Zip*
Date of Last Tetnus*
Insurance Carrier*
Policy Number*
Insurance Group Number if applicable
Name of Policy Holder*

First NameLast Name
Policy Holder Address (if different from student):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Place of Employment*
Work Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Does your child have any medication, dietary requirements, allergies or medical conditions we need to be aware of?
Please include any medication that needs to be given throughout the weekend.

Registration confirmation
YesNo
YesNo
By the issue of this letter I am authorizing the transportation, lodging, and feeding of participant named above. Should a medical emergency arise during a church activity or while traveling on such, I hereby grant permission to the activity leader or adult chaperone(s) to make whatever emergency arrangements are necessary, including the selection of physicians, paramedics, or other medical personnel and a hospital and/or clinic for the care of participant named above. I hereby give the medical personnel, hospital, and/or clinic my permission to hospitalize, treat, and to order injections, blood, anesthesia, or surgery as required for participant named above. I also understand that as a participant, my child may be photographed or videotaped during on- and/or off-campus activities, and these photos/videos may be used in promotional materials, group activities, and/or official church website. I, the undersigned, do hereby release and forever discharge Vinton Baptist Church, its employees, agents, and members from any and all claims past, present, and future, arising out of any illness or injury to participant named above. Further, I assume full financial responsibility for all physician, technician, medical, hospital, or other fees charged for such treatment.
Signature*
Date*

MonthDayYear
Date
I do hereby give my permission for myself and or my child to receive emergency medical care. In addition, I will not hold Passport, Inc., the host campus, or any mission partner agency responsible for any expenses, claims, or liabilities arising from any sickness or injury to my child or to me. In addition, I grant myself/my student the right to participate in any activities at/during camp. Finally, I understand that Passport, Inc. may use images of all camp participants on projection screens at camp and in future promotional materials.

A parent or legal guardian must e-sign for any participating minor and agree that they and the minor are subject to all the terms set forth above.
Signature*
Date*

MonthDayYear
Date
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it.
Should be Empty:

Vinton Baptist Passport Mission Trip

Participants Details

Emergency Contact

Emergency Contact 2

Medical Details

Registration confirmation