KUC Mission IMPACT 2009 Application
This form must be returned to the church by December 22, 2008 with a check for $100
payable to ‘Kenilworth Union Church’.
Applicant Name:____________________________________
Grade:________________ Date of birth:________________
Address:____________________________________________
City:____________________ State:________ Zip:_____________
Phone: (home) _______________ (student cell) _____________
Youth Email: _______________________________________
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Parent Names:______________________________________
Address (if different):_____________________________________
City:____________________ State:________ Zip:_____________
Phone: (home) _____________ (parent cell) ________________
Parent Email: _______________________________________
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Program Cost per participant: $1085
Program Cost without DR Trip $180 _______
Additional Donation for Scholarships
(Optional)
Total Enclosed
Please contact Sarah Garcia (847) 853-2104 or sgarcia@kuc.org if you would like to request an alternate payment plan or scholarship assistance.
Parental Permission / Release
I give permission for my son/daughter named above to participate in the
KUC Mission Program IMPACT, including all meetings, field trips, special events and the Dominican Republic Trip on June 5-13,
2009. You have advised me of the nature of the proposed activities, the transportation and the supervision
available and I consent fully to my child’s participation. I understand there are inherent risks
involved in any such activities, and I release the Church and all of its agents from any claim, whatsoever, arising out of
this activity. I accept responsibility for any damage caused by my child’s negligence or intentional
act.
Parent/Guardian Signature:
______________________________Date: _____________
Questionnaire
What
is your involvement with Kenilworth Union Church?
(Are you a member?
Music? Youth group? Sunday School? Does your family attend/belong? Do you have
a friend who is a member?))
Why are you interested in participating
in the KUC Mission IMPACT Program?
What are
some of the gifts, interests and skills you will bring to the group experience?
In what other service trips or projects have you participated?
All the activities
we have planned are an important part of the KUC mission program and so we ask participants to commit to coming to the majority
of the events in order to be part of the program. Please initial to the left of each KUC Mission IMPACT
event below if you have no anticipated conflicts and plan to attend. If you have a known
conflict on any of the dates, please explain in space to the right:
| Sun 1/11 – 7 pm | IMPACT Orientation | |
| Sun 1/25
– 4-6pm | Service Project | |
| Sun 2/1 – 10am | Bake Sale | |
| Sun 2/22
– 7pm | IMPACT Meeting | |
| Sat 3/7 – 6-9pm | Parents Night Out Fundraiser | |
| Sun 3/15
– 7pm | IMPACT Meeting | |
| Sun 4/5 – 7pm | IMPACT Meeting | |
| Sun
4/17-4/18 | Mini Mission Trip | |
| Sun 5/3 – 7pm | IMPACT
Meeting | |
| Sun
5/10 – 10:30am | Youth
Sunday Worship Service | |
| Sun 5/17
– 4-6pm | Trapeze Teambuilding Workshop | |
HEALTH INFORMATION
Known Allergies:
Anesthetics
Insect Stings
Penicillin
Aspirin
I.V.P. Dyes
Shellfish
Codeine
Morphine
Tetanus Toxoid
Demerol
Novocaine
Antibiotics (please list)
Other (please list)
Chronic
or Existing Medical Conditions:
(e.g., Asthma, Seizures, Diabetes,
Physical Challenges)
Medications
Needed During Travel
(please list all prescription and non-prescription
medications)
Dates of Most Recent Shots and Vaccines
(please list dates)
Tetanus:
Other:
Other:
Do you have emotional challenges? Y / N
If yes, please
explain.
Do you have any dietary restrictions? Y / N
If yes, please explain.
Parental Consent for Medical Treatment
Child’s Information:
Child’s name
Date of Birth
Parental Contact
Phone Number
Physician Contact
Phone Number
Kenilworth Union Church Staff and Agents shall be authorized
to administer and/or to consent for all medical treatment for the above-named child, which may be required during IMPACT activities,
field trips or the Mission Trip. If the injury or illness is life-threatening or in need of emergency treatment,
KUC staff and agents shall be authorized to summon any and all professional emergency personnel to attend to, treat and transport
the above-named child and to issue consent for any medical treatment or hospital care deemed advisable by, and to be rendered
under the supervision of, any licensed medical professional or institution duly licensed to practice in the state in which
treatment is to occur.
______________________________________
_____________
Parent / Guardian Signature Date
Health Insurance Information
Do you have health insurance? Y / N
Company Name:
Phone Number:
Group Number:
Policy Number:
Name of Primary Insured:
Date of Birth of Primary Insured:
IMPACT Covenant
As a KUC Mission IMPACT participant, I will abide by the following covenant. I
will:
_ Support the leaders and respect their authority.
_ Respect the views and feelings of the other IMPACT members and those of our hosts
at any location we visit.
_ Respect the environments I encounter
and refrain from intentionally causing damage to them.
_ Refrain
from all conduct that may reflect poorly on myself and the IMPACT team, including consumption of alcoholic beverages, use
of illegal drugs or tobacco.
_ Refrain from disrespectful language
and harmful behavior towards myself or others.
_ Attend and participate
in all IMPACT activities, including all vespers and devotions, contribute to team efforts, and share my experiences when I
return from the Mission Trip.
I understand that if I fail to abide by this covenant, I may be removed from the IMPACT program and
/ or returned home at my own expense.
Participant Signature:
______________________________Date:
_____________
Parent/Guardian Signature:
______________________________Date: _____________
