PERSONAL
INFORMATION
* This
registration is for:
--Choose Here--
Youth - 18 and younger
Adult Leader- 21 and older
* First Name
* Last
Name
* Address
* City
* State/Province
-- Select from List --
Alabama
Alaska
Alberta
Arkansas
Arizona
British Columbia
California
Colorado
Connecticut
Deleware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Manitoba
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Brunswick
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Nova Scotia
Ohio
Oklahoma
Ontario
Oregon
Pennsylvania
Prince Edward Island
Quebec
Rhode Island
Saskatchewan
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
Wisconsin
West Virginia
Wyoming
* Postal
Code
* Country
United States
Canada
* Phone
(
)
(xxx) xxx-xxxx
E-mail
Check here if you would like to receive emailed updates & information from Youth Unlimited.
Gender
Male
Female
* Birthdate
/
/
mm/dd/yy
* Name of Parent/Guardian with whom you reside
Relationship to you:
* Church
* Church
city
cit
(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?
YES
NO
PROFILE
Grade
completed by 7/1/10
YOUTH
PARTICIPANTS ONLY! !
-- Select A Grade --
Grade 6
Grade 7
Grade 8
Grade 9
Grade 10
Grade 11
Grade 12
College Level
* T-shirt
Size:
S
M
L
XL
XXL
Church
volunteer activities and special skills/abilities
(Check all that apply):
Taught Sunday School
Taught/assisted VBS
Active in Youth Group
Art/posters
Vocal talents
Clowning/mime
Community Outreach
Evangelism Training
SERVE Experience
ENCOUNTER Experience
Other Mission Experience
CPR/Lifesaving
First Aid
Foreign Language
Construction
Musical Instrument
Cross Cultural experience
Sports
Drama
Painting
Roofing
What
type of ministry would you prefer (check all that apply):
Sports camp
Day camp
Church plant
Evangelistic
Inner city ministry
Rural ministry
Home building/repair
Special needs
Bible school
Teaching
Overseas
*IF YOU ARE 18 or OLDER YOU MUST RESPOND TO THE FOLLOWING
Have you ever been convicted of or pled guilty or no contest to a crime?
YES
NO
Have you ever been convicted of any type of child abuse/sexual harrassment?
YES
NO
If you have a Driver's license, have you received any moving violations or points in the past five (5) years?
YES
NO
If you answered YES to any of these, please explain:
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
--SELECT 1st CHOICE--
Alamosa, CO [SITE FULL - MUST HAVE PR#]
Battle Creek, MI SITE FULL - MUST HAVE PR#]
Bellflower, CA [SITE FULL - MUST HAVE PR#]
Benton Harbor, MI [SITE FULL MUST HAVE PR #]
Byron Center, MI (Middle School) [7/24-7/30]
Disaster Response [7/24-7/30]
Edmonton/Leduc, AB [7/10-7/17]
Flagstaff, AZ [SITE FULL - MUST HAVE PR#]
Grand Rapids (Brookside), MI [SITE FULL - MUST HAVE PR#]
Grand Rapids (LaGrave), MI [SITE FULL - MUST HAVE PR#]
Hamilton, ON [SITE FULL - MUST HAVE PR#]
Holland, MI (Middle School) [8/1-8/6]
Howard City, MI [SITE FULL - MUST HAVE PR#]
Las Vegas, NV SERVE [SITE FULL - MUST HAVE PR#]
London, ON [SITE FULL - MUST HAVE PR#]
Minneapolis, MN [SITE FULL - MUST HAVE PR#]
Muskegon, MI [SITE FULL - MUST HAVE PR#]
Newark, NJ [SITE FULL - MUST HAVE PR#]
Niagara, ON [SITE FULL - MUST HAVE PR#]
Ontario, CA [SITE FULL - MUST HAVE PR #]
Ottawa, ON SPECIAL NEEDS [SITE FULL - MUST HAVE PR#
Platte, SD [SITE FULL - MUST HAVE PR#]
Rehoboth Camp, AB [7/24-7/31]
Thunder Bay. ON [SITE FULL - MUST HAVE PR#]
Vanastra, ON [7/03-7/10]
Vancouver, BC [7/03-7/10]
Washington DC (Silver Spring, MD) [SITE FULL - MUST HAVE PR#]
Washington DC (Fairfax, VA) [SITE FULL - MUST HAVE PR#]
Woodstock, ON [SITE FULL - MUST HAVE PR#]
Zambia, Africa [7/26-8/10]
Second
Choice
--SELECT 2nd CHOICE--
Byron Center, MI (Middle School) [7/24-7/30]
Disaster Response [7/24-7/30]
Edmonton/Leduc, AB [7/10-7/17]
Holland, MI (Middle School) [8/1-8/6]
Rehoboth Camp, AB [7/24-7/31]
Vanastra, ON [7/03-7/10]
Vancouver, BC [7/03-7/10]
Zambia/Kenya, Africa [7/19-8/11]
Third
Choice
--SELECT 3rd CHOICE--
Byron Center, MI (Middle School) [7/24-7/30]
Disaster Response [7/24-7/30]
Edmonton, AB [8/16-8/24]
Edmonton/Leduc, AB [7/10-7/17]
Holland, MI (Middle School) [8/1-8/6]
Rehoboth Camp, AB [7/24-7/31]
Vanastra, ON [7/03-7/10]
Vancouver, BC [7/03-7/10]
Zambia, Africa [TBD - 2 wks]
I
am arriving by:
Car
Minivan
12-pass Van
15-pass Van
Flying
Other
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
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**
If you have a DISCOUNT CODE enter it here:
Payment
Amount
--please choose correct payment amount--
$360 US (High School SERVE excl. CA, AZ, NV)
$310 US (Pre-Registered High School SERVE excl. CA, AZ, NV)
$300 US (Middle School SERVE)
$250 US(Pre-Registered Middle School SERVE)
$395 US (CA, AZ and NV sites)
$345 US (Pre-Registered CA, AZ or NV site)
$545 US (Disaster Relief)
$495 US (Pre-Registered Disaster Relief)
$1,845 US (Zambia)
$500 US (Deposit: Belize, Guatemala, Romania, Kenya/Zambia)
FULL amount due, unless you are going overseas.
All payments will be deducted in US dollars.
*Credit
Card Number
-
-
-
(we accept VISA, MASTERCARD and DISCOVER cards)
* 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 or possession
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/videos/
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.