* Required Field
Trip date* ---June 5 – 12, 2019 - Mifflin Presbyterian Church (open)June 12 – 19, 2019 - Worthington Presbyterian Church (open)June 19 – 26, 2019 - Bretheren Christian School (open)July 10-17, 2019 - Marietta First United Methodist Church, Marietta, GA (open)July 24-31, 2019 - First Presbyterian Church, Albemarle, NC (open)July 31- August 7, 2019 - First United Methodist Church of Gilbert, AZ (open)September 26-29, 2019 - Ambassador Trip (open)October 10-17, 2019 - Healthcare Service Trip (open)January 8-15, 2020 - Youth Across Borders (closed)Other
Church/Organization
Name exactly as it appears on your passport*
Name you preferred to be called*
Date of Birth*
Gender*MaleFemale
Age*If under 21, the notarized power of attorney form must also be completed
Shirt size*
Address*
City*
State*
Zip code*
Phone Number Home Work Cell
Profession*
Email*
Do you speak SpanishFluentlyModeratelyA littleNone
Special skills (i.e. construction, computer, musical, medical, etc.)
Special health concerns
Medicines currently taking
Special diet required
How did you hear about Montaña de Luz
Why do you want to participate in this experience
Emergency contact Name
Relationship
Phone NumbersDaytime
I give permission for Montaña de Luz to use photographs of me taken on the trip for promotional use. YesNo