Mission Trip 2023 – June 18th – 24th

Reserve and Pay for your Spot on the 2023 Mission Trip Here 

Complete the Required Next Step Participant Form Here

Complete the Brick Church Permission Form Below

Youth Activity Permission Form
Activity: Traveling between New York City and Boston Massachusetts for a Mission trip to work on roofing, flooring, wheel chair accessible ramps, porches, garages, and more.

Date of Activity: June 18 to June 24, 2023

Minor’s Full Name (as it appears on Gov’t issued ID):

Minor's Birthdate

Minor's Email

Minor's Cell Phone

T-Shirt Size

Minor's Address

Address Line 1

Address Line 2

City

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Covid-19 Vaccination

• No Vaccine
• First Does only
• Both Doses

Please Note: Vaccination is required to participate in this program.

I, __________________________, the parent or legal guardian of the above-named minor, hereby give my permission for his/her participation in the youth activities named above. I agree to direct my child to cooperate and conform to directions and instructions of personnel responsible for the activities. I agree that in the event my child is injured as a result of his/her participation in the above-named activities, including transportation to and from these activities, whether or not caused by the negligence (active or passive) of the activity or the church program, or any of its agents or employees; recourse for the payment of any hospital, medical , dental, or related costs and expenses will be paid either by me or my spouse, accident, hospital or medical insurance, or any available benefit plan of mine or my spouse. I consent to any x-ray examination, anesthetic, medical, or surgical diagnosis or treatment and hospital care under the general or special supervision and upon the advice of or to be rendered by a physical, surgeon, and dentist licensed under the Medical Practice Act and Dental Practice Act. As parent or legal guardian, I am responsible for the health care decisions of my child and am authorized to consent to services to be rendered, and no other consent is required by law. I hereby give permission to the physician selected by the activities supervisory personnel then present to render medical treatment deemed necessary and appropriate by the physician or dentist.

Parent or Legal Guardian Signature

Date of Signature

Relationship to Minor

Day Time Phone

Evening Phone

Cell Phone

Email *

Secondary Contact Name (Parent or other)

Daytime Phone

Secondary Contact

Evening Phone

Secondary Contact

Cell Phone

Secondary Contact

Email *

Secondary Contact

Name of Primary Doctor

Phone of Primary Doctor

Does Participant have any allergies? *

• Yes
• No

Please detail participants allergies

Does Participant take any medication

• Yes
• No

Please list medications and conditions for which they are taken

Additional information about the participant’s medical history:

Name of Insurance Company

Insurance Policy Number

Phone numbers for verification by emergency room staff

Address of Insurance Company

Address Line 1

Address Line 2

City

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Expiration Date (if any)

Employer

Name of Policy Holder

Submit