South Dakota Mission Trip 2022 Participant Information First Name* (As it appears on your driver’s license): _______________________________ Middle Name* (As it appears on your driver’s license): ___________________________ Last Name* (As it appears on your driver’s license): ______________________________ *This is the name used to purchase airline tickets, so please make sure it is exact and legible. Birthdate: _________________ mm/dd/yyyy
Cell Phone Number: ____________________________ Email: ______________________________________ Home Address: _________________________________________________________________ T-shirt Size; ________________ Beneficiary Name (for insurance purposes): ______________________________________ Beneficiary Phone Number (for insurance purposes): ______________________________ Emergency Contact Name and Number (if same as beneficiary, write “same”):______________ _____________________________________________________________________________ What church are you a member of? ____________________________________________ Have you attended the sentinel security training? Please circle: Yes or No If yes, where and when, if you remember? ___________________________________________ What skills do you have that may be of use on the trip? (I.E. Speaking Spanish, teaching, singing, coaching/playing a sport, painting, cooking, construction, crafts, etc.)
Please sign and date below as a representation that the above information is accurate to your knowledge and to give Jackson County Baptist Association permission to fill out required forms for the trip on your behalf using this information. ____________________________ Signature
__________________ Date