2019 Mission Trip Registration * = Required field Trip 1 xxx - SBP - May 19 - 25 Trip 2 xxx - SBP - June 23 - 29 Select trip:* xxxxxx DATA PRIVACY AND EMAIL COMPLIANCE Data collected electronically from this registration form will be used only for trip planning, and we agree to protect your personal data to our fullest extent. Also, we rely on email to communicate with you about trip details. You have the right to opt out of providing personal data. Consent to collect data:* Do you give DreamBuilders permission to gather and process your registration data? I agreeI don't agree You may withdraw consent at any time, via our "email us" link at the bottom of this page. If you choose not to provide registration data electronically, we will be unable to process your registration. Consent to contact:* Do you give DreamBuilders permission to contact you (and if applicable, your teen missioner) via email? I agreeI don't agree You may withdraw consent to contact at any time by specifying “DreamBuilders may not email me/us regarding trip(s)” in the comments section via our “email us” link, at the bottom of this page. If you choose to no longer receive trip communications, you or your teen will be unable to participate in this trip. MISSIONER DETAILS Last Name* First Name* Middle Initial* Name on driver's license or government-issued id (for airline ticketing)* Nickname (for nametag) Missioner email* Missioner Cell Phone* (required phone format: 10 digits, no spaces) Street Address* City, State, Zip* Gender MF Age Category Adult=18+Teen EMERGENCY INFORMATION Parent/Guardian Name* Parent/Guardian email* Parent/Guardian work phone* Parent/Guardian cell phone* Emergency Contact Name* Relationship* Daytime Phone* Evening Phone* Name of Second Emergency Contact* Phone of Second Emergency Contact* MEDICAL INFORMATION Physician* Physician Phone* Insurance Company* Policy Number* Insurance Phone* Date of Birth* (mm-dd-yyyy) Date of Last Tetanus shot* (yyyy-mm) Any Food or Non-Food Allergies?* YN List allergies (food and non-food) My teen may receive these over-the-counter medicines dispensed by the trip nurse: (control+enter or command+click for multiple options) ---AdvilAleveBenadrylDramaminePepto-BismolSudafedTylenol List any health matters we should be aware of regarding missioner participation for this trip: ADDITIONAL INFORMATION Congregation* ---AscensionChrist ChurchSt. MarksTemple IsaiahTrinityOther/None Specify Other Congregation (if applicable) If missioner is volunteering with a friend from a DreamBuilders congregation, please specify friend's name and congregation: DreamBuilders is in need of drivers, age 26 or older. (DreamBuilders will rent 7-passenger vans.) I am willing to be a mini-van driver Check all that apply: Missioner has been on a previous DreamBuilders trip Missioner previously helped on a local DreamBuilders project Missioner consents to being added to general DreamBuilders email list for periodic information about local projects, meetings, and fundraisers. You may "unsubscribe" at any time, via our "email us" link at the bottom of this page. If declined, missioner will only receive trip-related information. Missioner would like to join the DreamBuilders Leadership Team (Adults AND teens are welcome.) Missioner will travel separately T-shirt size* ---SMLXLXXLXXXL List anything else we should be aware of regarding trip participation: Please leave this field empty.