Registration Form for the April, 2026 Pilot Trip to Hazard, KY

* = Required field

DATA PRIVACY AND EMAIL COMPLIANCE: Data collected electronically from this registration form will only be used for trip planning, and we agree to protect your personal data to our fullest extent. 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 agree
I do not agree

If you choose not to provide registration data electronically, we’re 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 agree
I do not agree

“Unsubscribe” at any time via the “email us” link at the bottom of the dreambuildersmd.org home page by commenting “Please remove my email from DreamBuilders’ mailing list.” If you unsubscribe, you’ll only receive trip-related communications.

MISSIONER DETAILS

Last Name *

First Name *

Middle Initial *

Nickname (for nametag)

Missioner Email *

Email

Confirm Email

Missioner Cell Phone *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Gender

M
F

EMERGENCY INFORMATION

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 *

Do you have secondary insurance? *

Yes
No

Secondary Insurance Company *

Secondary Insurance Policy Number *

Secondary Insurance Phone *

Date of Birth *

Date of Last Tetanus Shot (yyyy-mm) *

Any Food and/or Non-Food Allergies? *

Yes
No

List Allergies (Food and Non-Food) *

List any health matters we should be aware of regarding missioner participation for this trip:

missioner) teen Second

ADDITIONAL INFORMATION

Congregation of Missioner *

Specify Other Congregation: *

Check All That Apply:

Missioner has been on a previous DreamBuilders trip
Missioner previously helped on a local DreamBuilders project (including desk builds)
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 website. If declined, missioner will only receive trip-related information.)
Missioner would like to join the DreamBuilders Leadership Team
Missioner will travel separately
Missioner is age 26 or older, AND is willing to be a driver during the trip

T-Shirt Size *

List anything else we should be aware of regarding trip participation: