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Home
The Team
XA Staff
Core Groups
Worship
House Staff
Find a Core Group
Core Groups
The Guys
The Ladies
Co-Ed
Events
Utah, Missions Trip 2024
Calendar
The XA House
House Staff
Residency
Give to XA House
Get Connected
Get Connected
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Facebook
Give
Application Form
SPRING BREAK - Utah, March 9th-16th, 2024
Cost: $450 | Deposit: $50
Full Name
*
First Name
Last Name
Mobile Number
*
(###)
###
####
Email Address
*
Date of Birth
MM
DD
YYYY
Gender at Birth
*
Male
Female
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Emergency Contact.
*
First Name
Last Name
Relationship to You
*
Mobile Number
*
(###)
###
####
Home Number
(###)
###
####
Email
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Allergies & Medical.
List any allergies you may have.
List any medical conditions that would affect this trip.
Are you currently taking any medication?
*
Yes
No
Doctor
*
First Name
Last Name
Phone Number
*
(###)
###
####
Insurance Company
*
Policy Number
About You...
*
Why are you interested in going on this trip?
Please tell us...
*
Describe your relationship with Jesus and your current devotional life.
Will you personally commit to honor team leaders, staff, church personnel, and those on the mission team? i.e. positive attitude, serve with a cheerful heart and respect others' requests.
*
Yes
No
Medical Release.
*
In the event of an injury or illness in which I become incapacitated and am unable to make medical decisions for myself, and Chi Alpha team leaders or their approved associates are unable to reach my emergency contact and/or my doctor, I authorize them to seek all necessary medical decisions on my behalf. I understand that Chi Alpha Campus Ministries and any of their associates will not be held responsible for any medical expenses incurred on the basis of this authorization.
Agree
Disagree
If you agree with the above statement
Signature: By typing my name in the box below, I understand that it will serve as my legal and binding signature.
First Name
Last Name
Date
*
MM
DD
YYYY
Liability Release.
*
With the intention of being legally bound, the undersigned hereby releases from liability and agrees to indemnify and hold harmless Chi Alpha Campus Ministries and its employees, representatives, and agents (responsible for arranging travel and overnight housing), for any and all liability for personal injuries (including death), property loss or damages resulting from activities, travel, overnight housing, and accommodation for this trip. The undersigned agrees to abide by all the rules and the regulations promulgated by Chi Alpha Ministries and their elected officials.
Agree
Disagree
If you agree with the above statement
Signature: By typing my name in the box below, I understand that it will serve as my legal and binding signature.
First Name
Last Name
Date 1
*
MM
DD
YYYY
Agreement & Signature.
*
By submitting this application, I affirm that the facts set forth in it are true and complete. I understand that if I am accepted, and false statements, omissions, or other misrepresentations made by me on this application may result in my immediate dismissal.
Agree
Disagree
If you agree with the above statement
Signature: By typing my name in the box below, I understand that it will serve as my legal and binding signature.
First Name
Last Name
Date 2
*
MM
DD
YYYY
Thank you!