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2019 Youth Mission Trip

We’re so excited that your child will be joining us as we journey to North Carolina to live and work in solidarity with the farmworker community

Please Complete this registration form

Participant Information
Please Register Students Individually
Participant Name *
Participant Name
Participant Phone (If applicable)
Participant Phone (If applicable)
Participant Address *
Participant Address
Primary Place of Residence
Participant Birthday
Participant Birthday
2019-2020 School Year
Health History
Please mark all conditions that apply to the participant (and provide further explanation below)
If you checked any of the boxes above, please explain. If there are other medical or behavioral issues we should be aware of, please write them here or email curate@stjohnsnh.org. Note: it's very hot and humid in NC in the summer and some of the work we do will be physically demanding,
Please list any medications that your child regularly receives.
Parent/Guardian Information
Parent/Guardian Name *
Parent/Guardian Name
Parent/Guardian Phone *
Parent/Guardian Phone
Please include the best number for us to call to get in touch with you
Parent/ Guardian 1 Alternate Phone
Parent/ Guardian 1 Alternate Phone
Parent/Guardian 2 Name
Parent/Guardian 2 Name
Parent/Guardian 2 Phone
Parent/Guardian 2 Phone
Name & Phone Required