2012-2013 Registration Form - Lipscomb Missions

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Lipscomb Missions > Mission Teams > Team Member Central > Registration Checklist > 2012-2013 Registration Form

2012-2013 Mission Trip Registration

* = Required Field

Trip Details
* Team Name:
* Time Frame:
Personal Information
* First Name:
* Last Name:
L Number (may not apply):
* Cell Phone:
* Gender:
* Date of Birth (mm/dd/yyyy):
* Email Address:
Campus Box:
* Classification:
* Major:
* Home Address:
* Home City:
* Home State:
* Home Zip:
* Home Phone:
Passport Information (All Information Required for International Trips Only)
Passport Status:
Legal name as listed on passport (First Middle Last):
Passport Number:
Expiration Date (mm/dd/yyyy):
Issuing City/Authority:
Issue Date (mm/dd/yyyy):
US Citizen
Emergency Contact Information
* Emergency Contact Name (First and Last):
* Relationship to you:
* Primary Phone:
Secondary Phone:
* E-Mail:
General Questions
* Would you like to receive SALT credit for this mission trip?	Yes No
*Note: if you select Yes above, you will be contacted by the SALT program with instructions on next steps. To view requirements for earning SALT credit, Click here
* How did you hear about this mission trip?
* Is this your first Lipscomb mission trip?	Yes No
* Do you have any food and/or drug allergies?	Yes No
* Are you currently taking any medications?	Yes No
* Have you ever been convicted of a crime (besides speeding)?	Yes No
* Mission trips have the potential to be physically demanding and emotionally challenging. Are there any physical, mental, emotional conditions that may keep you from fully participating in this trip?	Yes No
Team Member Covenant Agreement
The purpose of Lipscomb Missions is to equip every student with the knowledge of God's word and His purpose, along with a keen self-awareness which will lead them to identifying the plan God has for their life. By participating in a mission trip through Lipscomb University, you are awarded an amazing opportunity to serve alongside students, faculty, staff and alumni in various locations across the country and around the world. Understanding that you have chosen to volunteer for this opportunity, we ask that you take seriously the covenant agreement as set forth in the guidelines below. *PLEASE CAREFULLY REVIEW THE CHECK BOXES BELOW In accordance with the Lipscomb Missions Program, I agree to and understand the following:
	* I will submit my deposit as applicable to me within 7 days of completing this registration form. (A deposit must be paid by the individual or individual’s family, not a contribution from the fundraising portion of the trip).

	* I understand that my deposit and any contributions made to my trip are non-refundable.

	* I will complete a Waiver (University Release form) within 14 days of completing this registration form. Go to the Missions Center (Ezell 238) to pick up waiver; it can be completed there only on Wednesdays from 12 - 2pm. All other times, please take form to either The Connection (Post Office in student center) or Registrar's Office in the Crisman Administration building. Contact Julie Woodroof (julie.woodroof@lipscomb.edu) for more information. (Note: waiver must be signed & notarized).

	* I understand that I am responsible for any outstanding financial balance associated with my trip, even if I cancel my participation, per my team leader's discretion.

	* I commit to attending and participating in team meetings leading up to the mission trip.

	* I understand that failure to abide by these guidelines will result in my dismissal from the team prior to departure or being sent home at my own expense and that disciplinary action may be taken by the University.

2012-2013 Mission Trip Registration

Trip Details

Personal Information

Passport Information

(All Information Required for International Trips Only)

Emergency Contact Information

General Questions

Team Member Covenant Agreement