Mountain States Children’s Home Mission Trip 2026 Registration Form

Participant Info

Name

This address will receive a confirmation email

Phone

Address

Medical Release and Emergency Contact

To be filled out by parent or guardian if the participant is under 18

Insurance Provider

Policy #

Emergency Contact

Emergency Contact Phone

Special Conditions (i.e. allergies, diabetes, dietary needs, etc.)

Medications

As a parent/guardian, I give Tyler Flock, Meagan Flock, Kyle Williams, and other approved adult chaperones permission to seek any/all medical help for the above-named person as needed during the period of July 25-August 1, 2026.

Agree Disagree

My child can receive over the counter meds as needed (i.e. Tylenol)

Yes No

Trip Agreements

As a student of the West Main Church of Christ youth group attending the 2026 Summer Mission Trip, you agree that:

• I will make a good effort to complete all fundraising and spiritual formation requirements to attend.

• I will practice regular attendance to youth group and all meetings.

• I will listen to the instructions and requests of all adult chaperons on the trip.

• I will work hard to serve Mountain States Children’s Home Staff and Residents, without complaint.

• I understand that this is a Mission Trip, not a vacation, and I will seek to serve well and grow spiritually.

• I will encourage my peers on the trip!

Do you agree to these statements?

Yes, I agree No, I do not agree

Description

Please fill out this registration and click submit.

Mountain States Children’s Home Mission Trip 2026 Registration Form

Description

Please Fix the Following