Name (As it appears on Passport): *
Name (As it appears on Passport):
Phone: *
Phone:
Address: *
Address:
Date of Birth: *
Date of Birth:
Relationship: *
Phone:
Phone:
Address:
Address:
In Case of an Emergency, Please Contact:
In Case of an Emergency, Please Contact:
Phone:
Phone:
Address:
Address:
Waiver: In being accepted to participate in a short-term mission trip and activities associated with its program location, I assume responsibility for my actions. I release Calvary Chapel Carson City Christian Fellowship (5CF), its staff, trustees, employees, missionaries, agents or sponsors from liability, loss, injury or damage to myself or property. Nothing contained herein shall excuse 5CF, its staff, trustees, employees, missionaries, agents or sponsors from responsibility to act with reasonable care for the safety of myself or my property. I hereby release 5CF, its staff, trustees, employees, missionaries, agents or sponsors of the activity from responsibility and liability for any injury or illness that I may sustain during this activity. In the event of an emergency, I hereby authorize an adult leader of this activity, as an agent of myself, to consent on my behalf to medical treatment. In this regard, I consent to allow said adult to authorize medical, dental, or surgical diagnosis, X-ray examination, treatment including surgery, and hospital care for me if needed, and if advised and supervised by a licensed physician, surgeon or dentist.
(Father)
(Mother)
Confidential Medical Information:
Name:
Name:
Physician's Phone:
Physician's Phone:
Date of last Tetanus immunization or booster:
Date of last Tetanus immunization or booster:
Date of last Measles/Mumps/Rubella immunization or booster:
Date of last Measles/Mumps/Rubella immunization or booster:
Date of last Polio immunization or booster:
Date of last Polio immunization or booster:
Date of Hepatitis A vaccination:
Date of Hepatitis A vaccination:
Date of Hepatitis B Vaccination:
Date of Hepatitis B Vaccination:
Date of last chest X-Ray or TB Tine test:
Date of last chest X-Ray or TB Tine test:
Please Sign and Date
Please answer the following:
Any children under the age of 18 attending the trip with you, please contact the church office for information regarding paperwork you will need to have with you while traveling.
BEFORE SUBMITTING, FOLLOW LINKS BELOW FOR: BACKGROUND CHECK, STATEMENT OF FAITH, AND CONTRACT.

BACKGROUND CHECK

STATEMENT OF FAITH

CONTRACT

After reviewing ALL aspects of the application, please submit.