Teen & Guardian Application Need to download the printable version? It’s here. Step 1 of 5 - Personal & Contact Info 20% ApplicantName First Last Grade (Numeric)Date of Birth Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneEmail Enter Email Confirm Email What's the Start Date of the Mission you want to go on? Please select the start date for the Mission Trip you would like to attend. (These dates are found on the Upcoming Trips page of the website.)Ending date? Please select the end date for the Mission Trip you would like to attend. (These dates are found on the Upcoming Trips page of the website.)Parent/GuardianName First Last Email Enter Email Confirm Email PhoneAdult Supervising Teen on the MissionMust be approved by SGK/YSName First Last Date Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country PhoneEmail Emergency ContactSame as Parent or Guardian?Yes, same info.No, different person.Name First Last Relationship to ApplicantPhone - Cell*Phone - Other*Email Enter Email Confirm Email DocumentationRequired for all International TripsDo you have a valid US Passport ?YesNoPassport #US Passport numbers are between 6 and 9 alphanumeric characters.Passport Expiration Date How is your name listed on your passport?***You MUST apply for a passport ASAP. A copy must be submitted no later than two months prior to the trip.*** ***NO EXCEPTIONS***If you do not have a passport, do you have a registered birth certificate with a raised seal?YesNo Insurance InfoInsurance ComapnyInsurance Policy #Insurance Company Phone #Scan of Insurance CardIf you have a scanned copy or digital copy of your insurance card, you can upload it here.Medical InformationAre you allergic to any types of medication, food, animals, etc?YesNoIf yes, please explain: Please list any dietary restrictions: Will you be taking any prescription medication with you on the trip?YesNoListMedication Name:Reason for Taking:Dose:Frequency: Use the plus sign "+" to add more rows.Do you have any health or other problems which will effect your participation in the mission?YesNoPlease Explain: Teen Application QuestionsHave you previously been on a mission trip?YesNoIf yes, please explain: Where you went, when you went, and what you did.Do you speak Spanish?YesNoWhy do you want to go on this mission trip? What gifts and/ or skills do you feel you can contribute on a mission trip? What do you hope to gain from participating in a mission trip? How do you see your role as part of a mission trip team? What fears, if any, do you have about going on a mission trip? Is there anything else you want us to know about you? Liability Release & CommitmentIn order for your child to participate in an SGK / YS trip you must complete, sign, and return the following statement of consent and release of liability to us. As parent or legal guardian, you remain fully responsible for any legal action which may result from any personal actions taken by your child.I hereby consent to participation by my child,(Name of Teen) First Last in an SGK / YS mission trip. I understand that my child will be under the supervision of(Name of supervising adult) First Last I further consent to the conditions stated above on participation in this Mission Trip, including the method of transportation. I hereby waive and release any claim against SGK/YS for any injuries suffered by my child during such trip whether caused by the negligence of the designated supervisor or otherwise. In the event of an injury suffered during the transportation to and from the site, I agree to look solely to the insurance carrier providing insurance on the transporting vehicle for compensation. Medical Emergency Release: In case of medical emergency, I understand that every effort will be made to contact the parents or guardians of the participant. In the event that I cannot be reached, I hereby give permission to the physician selected by the supervising adult or other SGK/YS representative to hospitalize, secure treatment for and to order injection, anesthesia, or surgery for my child. Child: I agree that I am legally responsible for all/any personal actions I take during this trip, and agree to be financially responsible for any/all damages, legal fees, and other costs incurred as a result of my action/behavior. I will follow all the rules and regulations set forth by SGK/YS. Furthermore, I understand and agree that if at any time the trip leaders form the view that my conduct is inappropriate, unsafe and/or detrimental to the group, or if for any other unforeseen reason I must be removed from the group and returned to the United States, any travel plans or financial costs incurred as a result of my being sent home are my responsibility. I am responsible for helping my team to fundraise and will at the very least support my team in sending a minimum of 10 donation letters.Signature PreferenceI prefer to sign this form electronically on a mobile phone, tablet, or touchscreen device.I prefer to print, sign, and mail this form. I understand that may complete this form online, but that the application will remain incomplete until a printed and signed copy is received.If you select to print, sign and mail the form, a pdf of your completed form will be emailed to you for printing and signing.Parent/Guardian SignatureChild SignatureDate ________________________________________ Print parent/Guardian Name ________________________________________ Parent/Guardian Signature ________________________________________ Date ________________________________________ Print Child Name ________________________________________ Child Signature ________________________________________ Date shareClick to share on Facebook (Opens in new window)Click to share on Pinterest (Opens in new window)Click to share on Twitter (Opens in new window)Click to share on Google+ (Opens in new window)MoreClick to email this to a friend (Opens in new window)Click to print (Opens in new window)Click to share on LinkedIn (Opens in new window)Click to share on Tumblr (Opens in new window)
