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!
Student Groups
>
Association of Catholic Students
Mass stream
Bulletin
Register
Calendar
Support Newman
Annual Second Collections
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
Contact Fr Pius
Contact Fr Josh
Contact Andy Roybal
Contact Corinne
Contact Kathy
Contact Wells
Contact PMs
Contact Altar Flower Committee
FOCUS