Peru Immersion Trip Registration Form

Name

First

Last

Date of Birth (must be 21 or older to participate)

Address

Address Line 1

Address Line 2

City

State

Zip Code

Email

Gender

T-shirt Size

Passport Information

Name on Passport

First

Middle

Last

Passport Number

Date of Issue

Expiration Date

Emergency Contact

Name

First

Last

Relationship

Phone

Email

Medical Information

Dietary Restrictions

Allergies

Chronic Conditions

Personal Information

Your Parish

How are you involved in your Parish?

Tell us more about yourself, family, profession, education, etc.

Why are you interested in this trip?

What are your expectations for this trip

Describe any cross-cultural experiences you've had, particularly with economically vulnerable populations

Please rate your Spanish Speaking ability

Please indicate any medical training

Deposit

A deposit of $200 is required to reserve your spot.

Mail a check payable to:
The Center for Mission
ATTN: Peru Immersion Trip
777 Forest St.
St. Paul, MN 55106

Signatory

I understand my registration is not confirmed until the Center for Mission has received my $200 deposit. Furthermore, I agree to purchase and provide proof of travel insurance and comply with all entry regulations to Peru. I understand that a signed Risk and Release Agreement, and attendance at all orientation meetings is required as a prerequisite to travel, and failure to sign the Risk and Release Agreement, or the falsification of any information on this application will immediately disqualify me from participation. Any payments made for travel are non-refundable under these circumstances. By my signature, I acknowledge that I have read and agree to all policies and requirements for travel contained herein.

expectations populations Parish

Check box to agree

I agree to the above statement

Signature

Date / Time

Date

Time