Step 1 of 5 20% Name(Required) First Last Grade (Numeric) Date of Birth MM slash DD slash YYYY Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone(Required)Email(Required) What's the Start Date of the Mission you want to go on? MM slash DD slash YYYY 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.)Parent/GuardianName(Required) First Last Phone(Required)Email(Required) Adult Supervising Teen on the MissionMust be approved by SGK/YSName(Required) First Last Date(Required) MM slash DD slash YYYY Phone(Required)Email Emergency Contact Yes, same info. No, different person. HiddenDifferent Person InfoName First Last Relationship to Applicant Phone(Required)Second Phone NumberEmail DocumentationRequired for all International TripsDo you have a valid US Passport ? Yes No HiddenYes have PassportPassport #(Required) US Passport numbers are between 6 and 9 alphanumeric characters.Passport Expiration Date(Required) MM slash DD slash YYYY How is your name listed on your passport? Hiddenhave no 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? Yes No Insurance InfoInsurance Comapny Insurance Policy # Insurance Company Phone # Scan of Insurance CardMax. file size: 32 MB.If 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? Yes No If yes, please explain:Please list any dietary restrictions:Will you be taking any prescription medication with you on the trip? Yes No ListMedication Name:Reason for Taking:Dose:Frequency: Add RemoveUse the plus sign “+” to add more rows.Do you have any health or other problems which will effect your participation in the mission? Yes No Please Explain Teen Application QuestionsHave you previously been on a mission trip? Yes No If yes, please explain:Where you went, when you went, and what you did.Do you speak Spanish? Yes No Why 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 Preference I 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. Child Signature
