| Payment Date | Teen's Name | Parental/Guardian Permission & Authorization to Attend | Parent Signature | Date | Medical/Emergency Treatment Authorization: | Parent Signature | Date | Teen's Name | Teen’s High School | Year of HS Graduation | T-Shirt Size | Teen's Date of Birth | Teen’s Home Church | Teen's Email | Teen's Cell Phone | Teen's Address | Parent/Guardian 1 Name | Parent/Guardian 1 Cell Phone | Parent/Guardian 1 Email | Parent/Guardian 2 Name | Parent/Guardian 2 Cell Phone | Parent/Guardian 2 Email | Emergency Contact | Emergency Contact Phone | Emergency Contact Email | Relationship to Child | Physician and Health Information | Child’s Physician Name | Child’s Physician Phone | Policy in the Name of | Insurance Company | Insurance Policy Number | Insurance ID Number | Allergies/Dietary Restrictions | Current Medications | Any Additional Information You’d Like Us To Know | I give my permission for my child to receive email and text communication from Saint Anne Youth Ministry. | I give my permission for my child to be photographed/videoed while both preparing for and on this trip for possible use in website/bulletin/social media advertising by Saint Anne Youth Ministries. | Mission Trip Code of Conduct: | Teen's Printed Name | Teen's Signature | Date | Parent's Printed Name | Parent's Signature | Date | Total | Payment Amount | Payment Status |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Payment Date | Teen's Name | Parental/Guardian Permission & Authorization to Attend | Parent Signature | Date | Medical/Emergency Treatment Authorization: | Parent Signature | Date | Teen's Name | Teen’s High School | Year of HS Graduation | T-Shirt Size | Teen's Date of Birth | Teen’s Home Church | Teen's Email | Teen's Cell Phone | Teen's Address | Parent/Guardian 1 Name | Parent/Guardian 1 Cell Phone | Parent/Guardian 1 Email | Parent/Guardian 2 Name | Parent/Guardian 2 Cell Phone | Parent/Guardian 2 Email | Emergency Contact | Emergency Contact Phone | Emergency Contact Email | Relationship to Child | Physician and Health Information | Child’s Physician Name | Child’s Physician Phone | Policy in the Name of | Insurance Company | Insurance Policy Number | Insurance ID Number | Allergies/Dietary Restrictions | Current Medications | Any Additional Information You’d Like Us To Know | I give my permission for my child to receive email and text communication from Saint Anne Youth Ministry. | I give my permission for my child to be photographed/videoed while both preparing for and on this trip for possible use in website/bulletin/social media advertising by Saint Anne Youth Ministries. | Mission Trip Code of Conduct: | Teen's Printed Name | Teen's Signature | Date | Parent's Printed Name | Parent's Signature | Date | Total | Payment Amount | Payment Status |