SERVE Spring Break Jr. High

SERVE Mission Trip Jr. High Registration

If you have already registered but need to make a payment, please click here.

March 13 - 17, 2012 | $300
Jr. High Student
Registration Form

Student Information
Last Name*	First Name*	Sex*

Grade*		Date of Birth*

Address*

City*		Zip Code*

Cell Phone		Adult Shirt Size*
Student's Email
Parent Information

Parent or Legal Guardian Name*		Phone*

Parent or Legal Guardian Name		Phone

Email*

Emergency Contact

Name*		Phone*

Name*		Phone*

Insurance Information

Medical Insurance*		Phone*

Group #*		Policy #*

Company Address*

City*		Zip*

Physician's Name		Phone

Medical Information

Limitations (asthma, diabetes, allergies, etc.)
Date of last tetanus shot?
My child may be given Tylenol or Ibuprofen

My child may be given Benadryl.
















To complete your registration form for Jr. High SERVE 2012 \| Bay St. Louis, MS you must click the word submit below and you will be directed to our secure online payment system.* If you prefer to pay by check you may close your browser or click on the registration form link and return to this page. If you would like to return to the payment page later, you may do so at anytime by returning to this page or accessing the store via the Connecting Resources menu and selecting the bookstore and then events. *Please note: Registration is not complete until the non-refundable deposit has been submitted.

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