Week of Service

July 18-22

Cost- Suggested donation of $25 for tshirt and transportation.

**Complete this form as well as the Hold Harmless Agreement and payment by July 13, 2022**

 

Personal Information
Name
  •  
Date of Birth //
  •  
Student Cell Phone Number --
  •  
Student E-mail Address
  •  
Name of Parent(s)/Legal Guardian(s)
  •  
Address of Parent(s)/Legal Guardian(s)
  •  
Parent Phone Number --
  •  
Parent/Guardian E-mail Address
  •  
Tshirt Size
  •  
Days I'm Available
  •  
Please check any days you are unable to attend. If unsure, leave blank.
Medical Information
Family Physician
  •  
Phone Number of Physician --
  •  
Allergies
  •  
Current Medications
  •  
Medical History
  •  
In Case of Emergency, Please Contact:
Name
  •  
Phone --
  •  
Name 2
  •  
Phone 2 --
  •  
  •  
 
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Online Giving

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