Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone *

(###)

###

####

Cell Phone *

(###)

###

####

Other Adult

First Name

Last Name

Agreement *

I agree that is registration is showing my intention to participate with St. John's on the New Americans mini-mission trip to Fargo.

I agree, (youth must have a parent form signed)

I do not agree.

Medical permission *

I give the leaders of St. John's mission trips to medically treat my child both in house and at a medical center if the need should arise. And I know I will be contacted as soon as possible should this happen.

I agree