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Appalachia Mission Volunteer Form

- Ministries

Appalachia Mission 2020 Student Registration
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- This is OFFICAL REGISTRATION for the Appalachia Mission 2020, which runs from June 27th to July 4th. Cost is $300. Scholarships are available for High School Students, and College Students attend for free . In addition to this registration, a parent signature will be required for all student (under 18) registrations.
- Family's Home Parish Please enter valid data.
- Student Information
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Phone Number REQUIRED Please fill out this field. Please enter a phone number.
  
  Email Please enter an email address.
  
  Street Address REQUIRED Please fill out this field. Please enter valid data.
  
  City REQUIRED Please fill out this field. Please enter valid data.
  
  State REQUIRED Please fill out this field.
  
  Zip REQUIRED Please fill out this field. Please enter a zip code.
  
  Grade REQUIRED Please fill out this field.
  
  School Please enter valid data.
  
  Date of Birth REQUIRED Please fill out this field. Please enter valid data.
  
  Gender REQUIRED Please fill out this field.
  
  T Shirt Size (unisex adult sizes) REQUIRED Please fill out this field.
- Parent Information
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Relationship to student
  
  Phone Number REQUIRED Please fill out this field. Please enter a phone number.
  
  Email REQUIRED Please fill out this field. Please enter an email address.
  
  First Name Please enter valid data.
  
  Last Name Please enter valid data.
  
  Relationship to student
  
  Phone Number Please enter a phone number.
  
  Email Please enter an email address.
  
  I/we, the parent(s)/guardian(s) of the above mentioned child, for myself/ourselves and for my/our child, give permission for my/our child to participate in Appalachia Mission 2020 in Preston County, West Virginia. I understand that my child (if over the age of 16 at the time of the trip) will be using power tools. Training on the safe use of these tools will be provided.
  I Agree Please select this field.
  
  I/we, the parent(s)/guardian(s) of the above mentioned child, for myself/ourselves and for my/our child, give permission for my/our child's photograph to appear in promotional materails and social media platforms for the purpose of supporting the Appalachia Mission and the Catholic Church of Preston County Summer Home Repair Program.
  I Agree Please select this field.
  
  Medical Authorization
  In the event of any injury or illness to my/our child during his/her participation in Appalachia Mission 2020, I/we hereby give my/our permission for the necessary medical treatment to my/our child. I/we, agree that in case of injury to my/our child, I/we will apply my/our hospitalization and/or accident insurance toward payment of the expenses incurred and will not look to St John Neumann, Assumption, or Sacred Heart parish or any of it's employees or volunteers, or the Roman Catholic Diocese of Pittsburgh for the payment of any medical costs or injury related costs.
  I Agree Please select this field.
  
  Insurance Company REQUIRED Please fill out this field. Please enter valid data.
  
  Policy Number REQUIRED Please fill out this field. Please enter valid data.
  
  Consent To Treat
  I/We, the undersigned parent(s)/guardian of the participant named above, a minor, do hereby authorize treatment of my/our child by a licensed medical physician in case of any accident or illness that may so arise, or any hospitalization necessary.
  I Agree Please select this field.
  
  Medical Matters
  
  Medications: My child is taking medication at present. My child will bring all such medications necessary, and such medications will be well labeled. My child will be responsible to administer his/her own medication. REQUIRED
  1) Medications: My child is taking medication at present. My child will bring all such medications necessary, and such medications will be well labeled. My child will be responsible to administer his/her own medication.
  Please fill out this field.
  
  I hereby grant permission for nonprescription medication (such as Tylenol, throat lozenges, cough syrup) to be given to my child, if deemed advisable. REQUIRED
  1) Medications: My child is taking medication at present. My child will bring all such medications necessary, and such medications will be well labeled. My child will be responsible to administer his/her own medication.
  Please fill out this field.
  
  No medicating of any type whether prescription or nonprescription may be administered to my child unless the situation is life-threatening and emergency treatment is required. REQUIRED
  1) Medications: My child is taking medication at present. My child will bring all such medications necessary, and such medications will be well labeled. My child will be responsible to administer his/her own medication.
  Please fill out this field.
  
  Please list any known allergies REQUIRED Please fill out this field. Please enter valid data.
  
  Please list any physical limitations REQUIRED Please fill out this field. Please enter valid data.
  
  Is child subject to chronic homesickness, emotional reactions to new situations, sleepwalking, fainting? If yes, please explain below: REQUIRED Please fill out this field. Please enter valid data.
  
  Does your child have any other special needs? If yes, please explain below: REQUIRED Please fill out this field. Please enter valid data.
  
  Appalachia Mission 2020 Payment in Full*300.0
  
  *Scholarships are available! Please contact Gary Fritsch at gfritsch@sjnpittsburgh.org if you need partial or full financial assistance! We never want cost to get in the way of our teens participating in our events!
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