Summer 2010 Mission Registration Form

Presbytery of Western Kentucky

2010 High School Summer Mission Trip

Registration Form

Today's Date: __________________________________________

Name: __________________________________________________

Current Grade: ______ Birth Date: ______________________

Address: ________________________________________________

City/State: _______________________________ Zip: __________

Phone: __________________________________________________

Email: ___________________________________________________

Parent/Guardian Name: _________________________________

Parent/Guardian Phone: ________________________________

Church: _________________________________________________

Deposit Amount Enclosed: ____________

Note: please make checks payable to Presbytery of Western Kentucky

By signing this form, I am acknowledging that I am registering for the Presbytery's Summer mission trip to Swan Quarter, North Carolina. I understand that the total cost of this trip is $400 and that my $60 deposit is not refundable.

_______________________________________ ___________________________________

(Student Signature) (Parent/Guardian Signature)