<p> Heit's Point Lutheran Ministries - Lincoln, Missouri</p><p>Servant Events Dates will be attending ______</p><p>03/01/15- 03/31/15 07/01/15-08/01/15</p><p>Participant: </p><p>Please type or print neatly. Copy this form for all participants. </p><p>First Name: Last Name Initial: </p><p>Address: </p><p>City: State: Zip: </p><p>Phone: ( ) Email: </p><p>Current Grade Level: Birth date: / / Gender: (if a student)</p><p>Please check all that apply:</p><p> Youth Participant  Adult Participant  Group Leader  Pastor  Lay Leader  DCE, Youth Director</p><p>Congregation Information:</p><p>Name: </p><p>Address: </p><p>City: State: Zip: Phone:( ) </p><p>Adult Leader Name: </p><p>Travel Plans (if known)</p><p>Arriving by:  car/van  bus  train  plane</p><p>If by plane: Arrival Date: Time: Airline: Flight #: Departure Date: Time: Airline: Flight #: </p><p>If by auto/van, would you be willing to use it during the week if needed? Mileage will be reimbursed.  Yes  No</p><p>Personal Profile Previous Servant Event experience: </p><p>Other abilities, experiences, or interests that may be helpful for this Servant Event: </p><p>Special Needs: (medical, diet, etc.) </p><p>Required Signatures:</p><p>Participant Promise: I look forward to serving my Lord in this Event and I agree to participate and cooperate at all times.</p><p>Publicity Release: I give my permission to allow any pictures or videos taken during the Event to be used in publications by the Servant Event or by LCMS Youth Ministry.</p><p>(Participant's Signature) Date</p><p>Parent /Legal Guardian Permission: I give my permission for my son/daughter to participate in this Servant Event. Publicity Release: I give my permission to allow any pictures or videos taken during the Event to be used in publications by the Servant Event or by LCMS Youth Ministry. Participant List: I give my permission for my son/daughter's name, address, phone number and email to be included and shared by way of the participant list with others at this Event and LCMS Youth Ministry.</p><p>Parent/Legal Guardian Signature Date</p><p>Please mail this completed form along with deposit payable to: Heit's Lutheran Ministries</p><p>Deadline is: Deposit of $25 per person is due NOW. Remaining balance of $225 is due upon arrival (but can be paid in advance)</p><p>Mail to: Heit's Point Lutheran Ministries 28345 Heit's Point Avenue Lincoln, MO 65338 Email [email protected] for any questions or concerns, or call Heit's Point at (660) 668- 2363, and ask for Steven. </p><p>FOR OFFICE USE ONLY: Date received: </p><p>Deposit: </p><p>Balance Due </p>