Mission Trip Registration

* Indicates required field

Name *

First

Last

Address *

City/State/Zip *

Home Phone Number *

Cell Phone Number *

Birthdate *

Email *

Alternate Emergency Contacts:

Name *

Relationship to Child *

Phone Number *

Name *

Relationship to Child *

Phone Number *

Please list anyone else who you authorize to pick up your child/ren in your absence, while in the care of PPC

Name *

Phone Number *

Name *

Phone Number *

Please list any family situations we should be aware of: *

Please list any allergies or health concerns: *

Privacy Information:
All the information recorded on this form is collected and managed in accordance with the PPC Church Privacy Policy. This information has been collected for the primary purpose of PPC and may be used for any children's activities conducted or promoted by PPC.

Permission to Participate in Program Activities:

I consent to my child taking part in the approved program of activities. *

Yes

I give my permission for my child(ren) to be photographed or videotaped. I understand that these images may be displayed in PPC's church publications, church buildings or website. I understand as a precaution my child's name will not be published or linked with photographs. *

Yes No

I authorize the leader/s in charge of the above mentioned group where it is impractical to communicate with me, to arrange for my child to receive such medical treatment as the leader/s may deem necessary at any time during the activities of PPC. I appreciate that every care will be taken by the leaders and those connected with the group cannot be held responsible for personal injury, loss or theft of property affecting my child. *

Yes

Form Completed By *

First

Last

Date completed *

Relationship to child *

* Denotes required fields which must be completed in order to submit this form.

Submit

Mission Trip Registration

Privacy Information:All the information recorded on this form is collected and managed in accordance with the PPC Church Privacy Policy. This information has been collected for the primary purpose of PPC and may be used for any children's activities conducted or promoted by PPC.

Privacy Information:
All the information recorded on this form is collected and managed in accordance with the PPC Church Privacy Policy. This information has been collected for the primary purpose of PPC and may be used for any children's activities conducted or promoted by PPC.