Heit's Point Lutheran Ministries - Lincoln, Missouri

Heit's Point Lutheran Ministries - Lincoln, Missouri

Servant Events

Dates will be attending ______

03/01/15- 03/31/15

07/01/15-08/01/15

Participant:

Please type or print neatly. Copy this form for all participants.

First Name: Last Name Initial:

Address:

City: State: Zip:

Phone: ( ) Email:

Current Grade Level: Birth date: / / Gender: (if a student)

Please check all that apply:

q Youth Participant q Adult Participant q Group Leader

q Pastor q Lay Leader q DCE, Youth Director

Congregation Information:

Name:

Address:

City: State: Zip: Phone:( )

Adult Leader Name:

Travel Plans (if known)

Arriving by: q car/van q bus q train q plane

If by plane: Arrival Date: Time: Airline: Flight #: Departure Date: Time: Airline: Flight #:

If by auto/van, would you be willing to use it during the week if needed? Mileage will be reimbursed.

q Yes q No

Personal Profile

Previous Servant Event experience:

Other abilities, experiences, or interests that may be helpful for this Servant Event:

Special Needs: (medical, diet, etc.)

Required Signatures:

Participant Promise:

I look forward to serving my Lord in this Event and I agree to participate and cooperate at all times.

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's Signature) Date

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.

Parent/Legal Guardian Signature Date

Please mail this completed form along with deposit payable to: Heit's Lutheran Ministries

Deadline is: Deposit of $25 per person is due NOW.

Remaining balance of $225 is due upon arrival (but can be paid in advance)

Mail to: Heit's Point Lutheran Ministries

28345 Heit's Point Avenue

Lincoln, MO 65338

Email for any questions or concerns, or call Heit's Point at (660) 668-2363, and ask for Steven.

FOR OFFICE USE ONLY:

Date received:

Deposit:

Balance Due