West Virginia Mission Trip 2019

Register Now!


Who: 
High school students, completing grades 9-12

When:
 Sunday, July 14 - Saturday, July 20

Where:
 Philippi, West Virginia

What:
 We will be staying at the Chestnut Ridge Community Center in Philippi (our group has helped build this site over the years), but we will be working in both Philippi and Belington. Our major focus each day will be working on homes in the community for people who are less fortunate than we are. We will spend our evenings back at the center reflecting on the day and making time for praise and worship.

How much:
 A $50 deposit will secure your spot on the trip. The sign-up deadline is June 12th. The trip will cost $450 in its entirety, but our fundraising efforts (garage sale, Morning Stop) will help to reduce this cost. Individual costs may vary due to your participation in these fundraisers.

Still have questions?
 Contact Pastor Dave or Jess Rubican, or call the church office at 412-833-6111.

Due to the nature of this trip, please be aware that late drop-offs and early dismissals must be coordinated in advance and are not encouraged.

- - -

Permission for Emergency Medical Treatment:
By submitting this registration form, I do hereby give my permission for emergency medical treatment to be administered to the person who is the subject of this form.  I understand that all reasonable attempts will be made to contact me as soon as possible after the condition necessitating treatment arises and that, failing to reach me, all reasonable attempts to reach the person listed below as the emergency contact will be made.  I understand that every precaution will be taken for safety at all times.  I further release Peters Creek Baptist Church and their representatives or sponsors from liability associated with any accident, injury, or disease to the person who is the subject of this form.

 



Paying Now or Later?


Student Information

*First Name
*Last Name
*Address
Apartment If Applicable
*City
*State
*Zip Code
*Email
*Home Phone (XXX-XXX-XXXX)
Cell Phone (XXX-XXX-XXXX)
*Birthdate (mm/dd/yyyy)

Parent/Guardian Information

First Name
Last Name
Email
Home Phone (XXX-XXX-XXXX)
Cell Phone (XXX-XXX-XXXX)

Health Information

Health Insurance Company
Health Insurance Policy Number
*Known Health Issues
*Allergies and any medication you will be taking during the event

Emergency Contact Information

*First and Last Name
*Relationship
*Home Phone (XXX-XXX-XXXX)
Cell Phone (XXX-XXX-XXXX)

Grade & Shirt Size

Grade 2018-2019
Shirt Size

*Electronic Signature


*Participant Electronic Signature
*Parental Consent, by signing this I agree that I am the parent/guardian of this participating youth

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6300 Library Road | South Park, PA 15129
(412) 833-6111


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