2015 PCM Spring Break Mission Trip Silver City, New Mexico

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1 2015 PCM Spring Break Mission Trip Silver City, New Mexico DATES: March 14-18, 2015 DESCRIPTION: We will be traveling to the historic small town of Silver City, New Mexico and partnering with First Presbyterian Church of Silver City. Our goals are to come together and represent the Body of Christ that is Presbyterian Campus Ministry through worship, spiritual growth, relationship building, exposure to a different culture, and connecting to a local community of faith. We will serve a local ministry/mission in Silver City and also have time to learn about the history & needs of that community. COST: $ including a $50.00 non-refundable deposit due with registration. >This cost includes transportation, lodging, food, and a donation to local partners. Scholarship money is available. Don t let money stop you from going! DEADLINE TO REGISTER IS TUESDAY, DECEMBER 9 th. FINAL PAYMENT DUE MARCH 2 nd. TEAM MEETING DATES are MANDATORY! ALL MEETINGS HELD AT THE CAMPUS CHRISTIAN CENTER! FIRST TEAM MEETING WILL BE AFTER PCM ON TUESDAY, JANUARY 13 TH. COST & PAYMENT o $50.00 deposit (non-refundable) is due + another $ that you fundraise. o TEAM FUNDRAISERS ARE MANDATORY! All funds from the team fundraisers we plan will be evenly split among the team members! o CHURCHES ARE WILLING TO GIVE YOU MONEY FOR MISSION! A form letter is available for you to write a letter to your church s mission committee! They will ask you to report about the trip upon return. o DON T LET MONEY STOP YOU FROM GOING! If God wants you to serve in this way, God will provide! o For any money you raise over the $250.00: Up to $50.00 will be given to you for spending on the trip (cash upon departure) Remaining $$ will be set aside in the mission fund for your own future mission trips (not retreats) If you are a senior, you can donate the additional $$ to the Spring Break Mission Trip fund for scholarships. Registration form (5 pages)

2 Name: Address: City/State/Zip Phone Number: Year: Major(s): PERSONAL STATEMENTS In your own words, what is the purpose of the Silver City, NM Mission Trip? What do you expect to receive/learn? What do you expect to give/share? Describe your devotional life and how you are growing in your Christian life. How has God been preparing you for this experience? List any previous national or international travel experience, including the location and date(s): Do you speak, read and/or write any foreign language? If so which language(s)? What is your skill level? PCM SPRING BREAK MISSION TRIP REGISTRATION PAGE 1

3 MEDICAL INFORMATION AND RELEASE Name: Last Middle First Address: Street City, State, Zip Tel #: Date of Birth: Insurance Company: Policy #: Group #: Allergies: Medications: Current Medical Conditions: Previous Operations, Surgeries, or Serious Illnesses: Year: Year: Year: Blood Type: Immunizations (fill in date): Tetanus Hepatitis A Hepatitis B Typhoid Other ***Please make a copy of your insurance card and turn it in with this registration.*** OR Check here if PCM already has your medical insurance information from a previous trip. PCM SPRING BREAK MISSION TRIP REGISTRATION PAGE 2

4 EMERGENCY CONTACT INFORMATION Primary Emergency Contact Name(s): Relationship: Tel#: Secondary Tel #: Skype Name: Alternate Emergency Contact Name: Relationship: Tel#: Secondary Tel #: Skype Name: MEDICAL RELEASE & AUTHORIZATION I, (name of participant), give my permission for the following designated approved leaders (Rev. Ellen R. Dawson) to secure any needed medical treatment for myself. If I am unable to make decisions on my own, they are authorized to make medical decisions for me to the best of their knowledge and ability. In addition, I hereby release Arizona Presbyterian Campus Ministry and its affiliates from liability for accidents or injuries during this trip and its activities. Signature: Printed Name: Witness Signature: Witness Printed Name: Date: PCM SPRING BREAK MISSION TRIP REGISTRATION PAGE 3

5 HOLD HARMLESS AGREEMENT & WAIVER OF LIABILITY ARIZONA PRESBYTERIAN CAMPUS MINISTRY (sponsoring body) is sponsoring the SILVER CITY MISSION TRIP (hereinafter referred to as the Mission Trip ) from March 14-18, I, (participant name), of (address), in consideration of the opportunity to participate in the Program, and in consideration of other obligations incurred, hereby agree as follows: 1. I fully understand that I may be traveling or staying in areas of the world that may have unstable political, economic, and security situations where acts of war, potential danger from lack of control over local population, terrorism, or violence could occur at any time. 2. I fully understand that I may encounter difficult climates and living conditions; that risks are present concerning means of travel, food, water, diseases, pests, and poor sanitation and other health-related situations. Medical or emergency medical treatment may be inadequate or not available. 3. I accept and assume all responsibility for my personal actions and any and all risks of property damage or personal injury that occur during or result from my participation, including potential injury while working. 4. With the above in mind, I fully understand and agree that the Arizona Presbyterian Campus Ministry, its staff and Advisory Committee Members, along with the Presbytery de Cristo and the Presbyterian Church (U.S.A.) shall not be responsible or liable in any way for any accident, loss, death, injury, or damage to myself or my property in connection with the Mission Trip, or any portion of the Mission Trip, even if the said injury or action is due to the alleged negligence of Sponsoring Body. Further, I do hereby agree to indemnify and hold costs and expenses (including, without limitation, reasonable attorney s fees) of whatsoever kind in connection with the Mission Trip or any portion of the Mission Trip. Further, I make agreement on behalf of my heirs, agents, fiduciaries, successors, and assigns. I waive, knowingly and voluntarily, each and every claim or right of action I have now or may have in the future against Arizona Presbyterian Campus Ministry related to the Mission Trip, even if any such claim or right of action is caused by Arizona Presbyterian Campus Ministry s negligence. 5. I hereby state that I am in good health and have all medications necessary to treat any allergic or chronic conditions, and I am able to administer such medications without assistance. If at any time during the Mission Trip I need emergency medical care and am not able to give consent because of my physical or medical condition, I authorize emergency medical care decisions to be made on my behalf, and I specifically release Rev. Ellen R. Dawson, the Mission Trip Leader, in making those emergency medical care decisions, from any and all liability associated with the said decisions. 6. This document does not release the Arizona Presbyterian Campus Ministry from gross negligence. 7. I HAVE READ CAREFULLY, AGREE TO, AND INTEND TO BE LEGALLY BOUND BY ALL TERMS OF THIS HOLD HARMLESS, WAIVER OF LIABILITY, AND EMERGENCY MEDICAL CARE AUTHORIZATION. Signature: Printed Name: Witness: Printed Name: Date: PCM SPRING BREAK MISSION TRIP REGISTRATION PAGE 4

6 Students, please read all aspects of this registration, and check that you have read them: In registering for the PCM Spring Break Mission Trip, I agree to comply by all rules, cooperate with the leader and other students, and represent PCM well. I understand that this Mission Trip is a combination of fellowship, service, and worship, and I agree to fully participate in all of the activities. I recognize that in being a part of this trip, there will be no alcohol, drugs, or illegal substances allowed during the trip. By signing this registration, I acknowledge that I will be expected to show kindness to all, work as a member of the team, and attend all of the meetings. I agree to pay the required amount before departure or, if necessary, make other arrangements with the PCM Campus Minister. I also give my permission for Rev. Ellen R. Dawson, Presbyterian Campus Minister to secure any needed medical treatment for myself. If I am unable to make decisions on my own, she is hereby authorized to make medical decisions for me to the best of her knowledge and ability. In addition, I hereby release Arizona Presbyterian Campus Ministry and its affiliates from liability for accidents or injuries during this retreat and its activities. Signature: Printed Name: Witness: Printed Name: Date: PCM SPRING BREAK MISSION TRIP REGISTRATION PAGE 5

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