Crossroads CYC

Mission Trip 2011 Registration

First & Last Name *

Birthdate *

Street Address *

City *

Zip *

T-Shirt Size *

Student Email *

Student Cell Phone *

Parent Email *

Home Phone *

Parent's Cell Phone *

Emergency Contact Name *

Emergency Contact Number *

Students Health (Medication/Allergies *

Insurance Information (Company Name, Policy # & Phone #) *

In case of emergency I give Douglas & Valerie Pierson of Crossroads Christian Youth Center permission to seek medical treatment for my child. * Yes No

Parent/Guardian Digital Signature *

Why do you want to participate in the Crossroads Mission Trip? *

In what area(s) is God working in your life now? *

Team Agreement * I will not bring my iPod, cell phone or other electronic device. (Students will be allowed to use a leaders phone if necessary)
I will not complain and will do my best to have a servant's attitude.
I will not use profanity.
I will encourage & pray for my teammates and leaders.
I will not use and/or purchase alcohol, drugs or tobacco on this trip.
I will adhere to the dress code established by CCYC, Bethlehem Baptist & Marie Sandvik Center.
I will turn in all money ($250) by Wed. July 13th. If I have not raised the full amount I will bring a personal check for the remaining balance.

I am willing to place myself under the authority of all Crossroads trip leaders, Bethlehem staff and the Marie Sandvik Center staff. * Yes No

I understand that if I choose to disregard this authority that disciplinary action will be taken and I may be sent home. * Yes No

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