ST THOMAS MORE CATHOLIC NEWMAN CENTER
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Register for the 2019 Mission Trip!
Dates of Trip: March 23-29, 2019
Destination: Henderson, Nevada
There are three sections to the registration form:
(A) Registration & Contact Info (B) Medical Information (C) Policy Agreement
Mission 2019 Registration Form
Part A: Registration & Contact Info
Name
*
First
Last
Permanent Address
*
Line 1
Line 2
City
State
Zip Code
Country
Temporary School Address
*
Line 1
Line 2
City
State
Zip Code
Country
Cell Phone Number
*
Home Phone Number
*
Email
*
Gender
*
Female
Male
Age
*
Birth date
*
Birth Place
*
Citizen of which country?
*
Have you had previous experience in going on a Mission Trip?
*
Yes
No
If YES please explain:
*
Languages spoken/degree of fluency
*
Do you have any building or painting experience?
*
What is one thing you are hoping to accomplish on this Mission Trip?
*
Part B: Medical Information
Your Name
*
First
Last
Choose Any
*
Male
Female
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Emergency Contact Info
Name
*
First
Last
Relationship
*
Home Phone
*
Cell Phone
*
Email
*
Please list any medical or first aid training you may have:
*
Are you presently being treated for an injury or sickness, or under a doctor's care?
*
Yes
No
If yes, please explain:
*
Please list any FOOD allergies or dietary restrictions:
*
Please list specific known allergies (Medicine, environmental, insect, etc.):
*
Date of last TETANUS SHOT:
*
Blood Type:
*
IMMUNIZATIONS:
MMR (Measles, Mumps, Rubella):
*
Yes
No
Hepatitis A:
*
Yes
No
Typhoid:
*
Yes
No
INSURANCE INFORMATION
Insurance/Health Plan Name:
*
Insurance Company Phone Number
*
Primary Insured:
*
Policy Number:
*
Member ID:
*
Group Number:
*
Part C: Policy Agreement
I will be spiritually, physically, and mentally prepared for this mission trip. This mission trip will stretch me and mold me in ways that I can only imagine. I will do everything I can ahead of time to prepare myself for a “trip of a lifetime.” I am a guest in New Orleans.
I will respect and follow the traditions of the local people; I agree to have a servant attitude at all times. When I am doing a task or ministry I do not particularly care for, I will participate while on the trip. I will have a positive attitude at all times. Every trip has its challenges and unforeseen circumstances. People could get sick, items lost, and plans changed. I realize that there are times I will need to “roll with the punches” and look at challenges as opportunities to be a witness for Jesus Christ.
I will attend all mission trip meetings and fulfill fundraising responsibilities . If I am not able to attend a meeting, I will contact a staff person to let them know. I understand that my deposit for this trip is non-refundable.
Date:
*
Do you agree?
*
Yes
No
Submit
Home
COVID Updates
New Here?
About
>
Our Mission
Visit Us
100 Years of Newman on UO Campus
Dominicans
Welcome Students!
Baccalaureate 2022
Newman Award
Student Groups
>
Association of Catholic Students
Mass stream
Bulletin
Register
Calendar
Support Newman
Support Student Retreats
Mass, Sacraments
Mass Times
Sacraments
>
Become Catholic
Infant Baptism
Confirmation
Marriage
Mass Intentions Calendar
Mass Request
Connect
Synod
Get Involved
>
Laudato Si
Liturgical Ministry
Music Ministry
St. Vincent de Paul Conference
Dominican Laity
Event Request Form
Contact Us
FOCUS