mission trip photo

On-line Registration
Please note: CREDIT CARD PAYMENTS ONLY .
If you prefer to pay with check, please fill out a paper registration form(available HERE) and mail it to Youth Unlimited. Sections with asterik (*) are required fields.

PERSONAL INFORMATION
*This registration is for:
*First Name
*Last Name
*Address
*City
*State/Province
*Postal Code
*Country
*Phone
( ) (xxx) xxx-xxxx
E-mail
Check here if you would like to receive emailed updates & information from Youth Unlimited.
*Gender
*Birthdate
/ / mm/dd/yy
 
*Church
*Church city
city

(Please use the city found in the church mailing address)
Pastor's Name
Pastor's Phone Number
( ) (xxx) xxx-xxxx
School
   
MEDICAL INFORMATION
*Date of last Tetanus shot
*Medical conditions, including allergies
*List medications you
take and side effects
Any disabilities or conditions that require accomodation?
 
 EMERGENCY CONTACT
*Name
City, State/Prov
*Day Phone
( ) (xxx) xxx-xxxx
Evening Phone
( ) (xxx) xxx-xxxx
Cell Phone
( ) (xxx) xxx-xxxx
 
INSURANCE
*Insurance Company
*City, State/Prov, Postal Code
*Phone
( ) (xxx) xxx-xxxx
*Subscribers Name
*Policy #
*Group #
Provincial Health Insurance # (Canada)
*Does your insurance company require pre-authorization for medical treatment?
 
PROFILE
Grade completed by 7/1/09
YOUTH PARTICIPANTS ONLY!!
*T-shirt Size:
Church volunteer activities and special skills/abilities
(Check all that apply):
First Aid Foreign Language
Construction Musical Instrument

What type of ministry would you prefer (check all that apply):
 
SITE CHOICES -- listed in alphebetical order according to city
Please Note: Be sure to look at the Missions Site Locations page to see which sites are full and no longer taking new registrations. If your first site is FULL and you do not put a second choice site, you will lose your spot in line for placement.
*First Choice
Second Choice
Third Choice
I am arriving by:
Do you have any notes for Youth Unlimited about this registration?
 
PAYMENT
You are required to supply FULL payment with this registration.
If you are using a pre-registered spot, please enter the pre-registration number below, and pay the remaining balance. If you are unsure of what your balance is, please e-mail missions@youthunlimited.org or call our office 616.241.5616 x3045.
Pre-registration Number (5-digit)
IF YOU ARE PART OF A PRE-REGISTERED GROUP, YOU MUST FILL THIS IN IN ORDER TO HAVE THAT PAYMENT APPLIED TO YOU.

**THIS FIELD MUST BE
FILLED IN IF YOU HAVE PRE-REGISTERED**
*What currency are you
using for your payment?
(US Dollars) (Canadian Dollars)
*Payment Amount

FULL amount due, unless you are going overseas.
*Credit Card Number - - -
*Expiration Date (mm/yy)
*Name on Card
Liability Waiver/Covenant/ Authorization/Release
 
Click HERE to read before moving on
In consideration of being allowed to participate in this project sponsored by Youth Unlimited (YU) and in consideration of the benefits to be derived therefrom, I hereby release YU and its present and former trustees, officers, directors, shareholders, employees, agents and their heirs, administrator, executors, successors and assigns from all claims and liabilities of any kind, whether known or unknown, which arise from or are connected in any way with my/my child's participation in this trip. I recognize that the conditions in some of the places to which I/my child will travel are not of the same standard as the conditions to which I/they are accustomed, I realize further that there are certain health risks as well as other risks I/my child will be exposed to while participating on this project. I fully acknowledge those risks. If for any reason I/my child am/is unable to complete my/his/her stay at the project, I assume full responsibility for the expenses incurred for my/his/her return home. I am also aware that any lack of respect for authority, including the use of abusive language, violations of site smoking policies, and failure to comply with behavioral expectations may result in my/his/her being sent home at my expense. I understand that any use of alcohol, firearms, weapons, or drugs (not prescribed by a physician) will automatically result in my/his/her being sent home at my expense.
In the event of an emergency, I hereby authorize a leader of this activity, as an agent for me, to consent to: any x-ray examination, medical, dental or surgical diagnosis; treatments; hospital care advised and supervised by a physician, surgeon or dentist (as appropriate) licensed to practice under the laws of the state or country where services are rendered, either at a doctor's office or in a hospital. I expect my emergency contact/I will be contacted as soon as possible. I understand that this document constitutes a full and complete waiver of all possible claims for any act of omission, including claims for negligence regarding injury or property damage, arising out of my/my child's participation in the trip. I understand that this release applies to, covers and includes unknown, unforeseen, unanticipated, and unsuspected damages, losses or liabilities and the consequences thereof, which result from the matters herein before inferred to as well as those now disclosed and
known to exist. The provisions of any state, federal, local, provincial or territorial law or statute providing in substance that releases shall not extend to claims or damages which are unknown or unsuspected to exist at the time are hereby expressly waived by me.
Student Participants Only: I agree to cheerfully participate in all assignments and activities and to abide by the decisions and schedules set by the YU host team and adult sponsors. I acknowledge that I am representing Jesus Christ, my church youth group and YU while on this mission trip and will conduct myself appropriately at all times. I do hereby certify that I promise to abide by the rules and regulations set forth therein.
Parent/Gaurdian: I certify that all information in this two-page application is correct and that I have read, understood, and agreed to all the provisions of the Liability Waiver / Authorization / Release as stated. I also give my permission for my son/daughter to be photographed for use in YU promotional materials including, but not limited to, printed brochures and web site photos/
promotions. My son/daughter's image will not be used for any other purpose than the promotion of YU.
Adult Leaders Only: I approve a police check to be done by YU, and I agree to cheerfully participate in all assignments and activities and to abide by the decisions and schedules set by the YU host team. I do hereby certify that I promise to abide by the rules and regulations set forth therein. I also give permission for myself to be photographed for use in YU promotional materials, including, but not limited to brochures and website photos/promotions. My image will not be used for any other purpose than the promotion of YU. I also certify that all information in this application is correct and that I have read, understood and agreed to all of the provisions of the Liability Waiver/Authorization/Release as stated. My pastor has approved me as capable of leading a small group.
 

When all fields are accurately and completely filled in, Click Submit.


 


missions menu