Mission Trips

Name *

First Name

Last Name

Phone *

(###)

###

####

Birth Date *

MM

DD

YYYY

Emergency Contact Name *

First Name

Last Name

Emergency Contact Phone *

(###)

###

####

Medical Info

Please check all that apply.

I have a medical condition.

I am on a daily medication.

I have an allergy.

I have dietary needs.

I understand and agree to the following. *

Please check all that apply.

I understand that I am signing up for the Alternative Spring Break trip to Philadelphia, PA.

I understand that the cost of this trip is $125 with a $25 deposit due upon submission of this form.

I understand that the volunteer work will be in various projects.

I understand that sleeping arrangements will be with other peers from the Newman ASB group.

I understand that, with any volunteer/mission trip, there exists a possibility of bodily injury or damage to belongings during travel and work.

I understand that my participation is voluntary in which I will receive no academic/monetary compensation.

I hereby release, relieve, and hold harmless the Newman Catholic Center, the Diocese of Springfield in Illinois, and its employees from any liability (including bodily injury, property damage, or death) arising from my participation in the mission trip, including travel to, from, and around locations of the program.

Payment Method - please add a memo of ASB to your payment *

Deposit of $25 due upon submission. Final payment due March 1.

Credit Card (made through the 'donate now' button)

Venmo (@eiunewman)

Check (made to EIU Newman Center)

Cash (paid in the office)