Mission Mover Submission

Mission Mover

Student's Info

First Name

Last Name

Birthdate

Gender

Phone Number

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Church and MTM Info

Amount Raised

Church Name & Pastor

Section Name

Church Address

Info For The Mission Mover Trip

If you have raise at least 1,000 dollars you qualify for the Mission Mover Trip. The follow medical information is Required if you qualify and wish to attend the trip. More information regarding trip dates, activities, and pick up locations will be communicated soon.

*If you gave and qualified for prizes but not the trip, please just answer N/A for the info Below.

Medical

Medication?

Yes

No

if so, please list medications

Allergies?

Yes

No

if so, please list.

Insurance Company and Policy Number

Can the Camp Nurse administrate medication if needed?

Yes

No

Emergency Contact

First Name

Last Name

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Phone Number

Email

Liability and Consent

I hereby release The Kentucky District and the Kentucky District Youth Department from all liability, claims, demands, causes of action and possible causes of action whatsoever arising out of or related to any loss, damage or injury that may be sustained by my child while attending Our Real McCoy Trip.

Signature