2023 SERVE Registration

Student Name

This address will receive a confirmation email

Phone

Address

Date of Birth

Gender

Male Female Option

T-Shirt Size

Small Medium Large Extra Large 2 XL 3 XL

Grade Completed By Summer 2023 9 10 11 12

Emergency Contact Information

Emergency Contact Name

Phone

Emergency Contact Relationship to Participant

Medical Information

Date of Last Tetanus Shot

List any medical conditions or medical dietary restrictions, including food or drug allergies (Please note we cannot accomodate food preferences, only dietary restrictions due to a medical condition)

List any medication you take regularly, what you take them for and applicable side effects.

Do you have any physical conditions or disabilities that will require additional accommodation?

Yes No

Do you currently have health Insurance?

Yes No

Does your Insurance company require pre-authorization for medical treatment? Yes No I don't know

Insurance Company, Policy #, group #, Insurance phone #

Talents, Skills, and Experience

How many years of Youth Ministry experience do you have?

Have you ever been on a SERVE Experience before?

Yes No

Are there any skills or talents you have that would be helpful for the host team to know?

Is there anything else that you would like the host team to know about you?

Adult Participant Specific Questions

Have you ever been convicted of, or pled guilty or no contest to a crime? Yes No

Have you ever been convicted of any type of child abuse, sexual harassment, etc?

Yes No

If you have a driver's license, have you received any moving violations or points in the past five years?

By checking this box you are agreeing to submit a background check (current= after June 15, 2019) to the ThereforeGo Ministries office by May 15, 2022 I agree

Terms and Conditions

ADULT PARTICIPANTS (21 AND OLDER)

All Adult Leaders (21 years and older) are required to complete and submit a current (within three years) background check to the ThereforeGo Ministries office. To be considered current for the 2022 SERVE season, the check must be completed after June 15, 2019.

I agree to cheerfully participate in all assignments and activities and to abide by the decisions and schedules set by the TGM Host Team. I do hereby certify that I promise to abide by the rules and regulations set forth therein. I also give permission for myself to be photographed or videotaped for use in TGM promotional materials, including, but not limited to brochures and website photos/promotions. My image will not be used for any other purpose than the promotion of TGM. I also certify that all information provided in my registration with ThereforeGo Ministries is correct and that I have read, understood and agreed to all of the provisions of the Liability Waiver/Authorization/Release as stated.

I have read and agree with the TGM Statement of Faith (found at www.youthunlimited.org/us/). I agree to lead small group discussions and personal conversations in a way that honors Jesus Christ and reflects the TGM Statement of Faith.

I agree to the terms and conditions.

Yes

Payment

The total cost for registration is $400 + the cost of transportation. The Youth Group Fund will cover all but $150 of the cost. You can use the form below to submit the registration fee or send payment to the church office.

Payment

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

2023 SERVE Registration

Description

Please Fix the Following