Missions on-line registration form
A non-refundable deposit of $150.00 is required per person for all trips except Mission Navajo. The non-refundable deposit for Mission Navajo is $170.00 per person.
Make checks payable to LCOH with the trip name in the memo and turn in to the front office.
When submitting your registration, please provide a copy of your insurance card (front & back). For international travel, you must also provide a copy of your passport and Visa.
To register a family, complete only one registration form and list all names and birthdates of those registering in the box requesting this information.
Type names exactly as they appear on your travel documents.
Mission trip registration
* Required
Address Line 1 *
Address Line 2
Email address *
Date of birth *
Gender
Marital status
List all family member names and birthdates who are also registering for this trip
Trip dates (check the trip dates for which you are registering) *
Jamaica: Jan. 19 - 26, 2008
Juarez 1: Feb. 9 - 16, 2008
Juarez 2: Feb. 16 - 23, 2008
Ghana 1: Feb. 27 - March 9, 2008
Navajo 1 (family): March 14 - 22, 2008
Mexico City (ages 18 and up): March 29 - April 6, 2008
Juarez 3 (Father/Son Trip): June 7 - 14, 2008
Navajo 2 (family): June 20 - 28, 2008
Ghana 2: July 23 - Aug. 3, 2008
ASP: July 26 - Aug. 2, 2008
Ghana 3: July 30 - August 10, 2008
Navajo 3 (adult): Sept. 12 - 20, 2008
Have you been on this trip before?
If you know of someone who is participating in this trip and you would like to share a room, please type his/her name here
Emergency Contact Information
Name *
Relationship *
Home phone number *
Work phone number
Cell phone number
Please indicate any areas in which you are proficient
Please give details for any skills selected above or describe any other skills not listed *
Health Information
Health insurance carrier *
Policy number *
Carrier phone number *
Rate your general health
State any special needs (diet, lodging, lifting, etc.)
Indicate any health concerns
Indicate any allergies (environmental, food, medication)
Indicate date of last tetanus shot
List any medications you will be taking on this trip (note: if you are leaving the country, all prescription medications must be carried in the original containers)
Hope purchases missionary insurance on your behalf during the trip dates. Please provide the individual name(s) and phone number(s) to list as your beneficiary on the life insurance portion of the policy. Please list beneficiary name and phone number for each family member participating. *
Please complete for Mission Ghana, Mission Jamaica, Mission Juarez or Mission Mexico City
Passport number
Expiration date
Please complete this section for Mission Ghana only
Indicate date of yellow fever immunization (registrants must have proof of this vaccination to enter Ghana)
Indicate dates of hepatitis A immunization
Indicate dates of hepatitis B immunization
Indicate date of meningitis immunization
Indicate date of diptheria booster immunization
Indicate date of polio booster immunization
Indicate date of measles booster immunization
Indicate T-shirt size
T-shirt color (Mission Juarez only)
In the event of an emergency or non-emergency situation in which medical treatment is required as a result of participation with Lutheran Church of Hope, every reasonable effort will be made to contact the person(s) listed on this form. If unsuccessful in contacting the person(s) listed, consent/permission is given for treatment by competent medical personnel.
Further, unless specified otherwise, consent/permission is hereby given to all accompanying adult volunteer leaders on the trip to hospitalize, secure proper treatment for, and to order injection, anesthesia, or surgery (under recommendation of qualified medical personnel). If possible, the adult contact person for your group should make the final decisions in cooperation with medical personnel.
I understand that Lutheran Church of Hope does not carry accident or medical insurance on participating volunteers. I agree that my insurance company will be used for such medical care expenses and I am aware that I may be billed by the medical provider for any medical treatment expenses not covered by my insurance. I understand that if I do not have medical insurance coverage that I am responsible for the payment of any medical bills.
Signature (please type name) *
Date *