ADULT APPLICATION
2016 Parent/Teen
Guatemala Mission Trip
When: June 26 – July 5, 2016
Cost: $1450 per person *Money not due all at once, There is a payment schedule.
Price includes: Airfare, food, lodging at a hotel, transportation, ministry supplies,
and site-seeing and overnight in Antigua for cultural emersion trip. 
Only extra money you will need is for souvenirs, snacks and food for airport days of travel.
Application & $75 deposit per person due Dec. 13, 2015.
*We can take credit card payment, there will be a service charge fee.
Who can go: Teens in middle school or high school who are active members of the
Epicenter youth ministry. If you are in middle school, you need one parent to go with you on
this trip. If you are going to be in 9th grade in fall 2016, or currently in high school, then you may
go on this trip without a parent.
Examples of things we will be doing:
We will be working with our missionary Myra who runs a feeding clinic for mothers and
children. Our team will be doing a week-long Vacation Bible School. We will also be handing
out food and pigs at her feeding program.
Very Important Information: You will need a valid passport.
If you are a US citizen, all you need is a passport. If you are not a US citizen,
you will need to secure a VISA to get into Guatemala.
(Please check with the Guatemalan embassy with any questions or concerns.)
Youth Short Term Missions Application
Epicenter Youth Program
Immanuel’s Church ● 16819 New Hampshire Avenue ● Silver Spring, MD 20905
For more info, please contact Pastor Jenny, (301) 989-4673, x1279 or jchilders@immanuels.org
Please Print or Type your application.
Please insure your entire application is filled out and signed by your parents/guardians.
Dates of Trip: June
Today's Date:
26 – July 5, 2016
PERSONAL INFORMATION
(Please check one of the following) Male: _____
Female: _______
Name: _____________________________________________________________
(Please give your first and last name as it appears on your birth certificate.)
Do you have a nickname you prefer to go by? ______________________________
YOUR ADDRESS:
Phone: _______________________________________
When is your birthday?
Cell Phone: ___________________________________
__________________________________
Your E-Mail: __________________________________
Parents E-Mail: ________________________________
What is the best way to reach you?
____________________________________________
MEDICAL INFORMATION
Age: ________________
Are you allergic to any medication? _____________________
If yes, please specify: ___________________
If you have any special dietary considerations or allergies, please list them here: ___________
In case of an emergency while we are in Guatemala:
Relationship of person to you:
EMERGENCY CONTACT
___________________________________
Name: ____________________________
Address: _____________________________________________
Phone: ___________________________
_____________________________________________________
CONSENT FOR TREATMENT
In case of emergency, I hereby agree to the performance of such treatment, including anesthesia and surgery, as the
attending doctor or physician may deem necessary.
Parent Signature: _________________________________________________________
Youth Signature : __________________________________________________________
Date: ______________________
RELEASE OF LIABILITY
I do hereby release IMMANUEL’S CHURCH, its staff, pastors, agents and volunteer assistants from any liability
whatsoever arising out of any injury, damage or loss which may be sustained by myself or my family member during
the course of involvement with the short term mission outreach of Immanuel’s Church anywhere in the world.
Adult Signature: _________________________________________________________
Date: _________________
Mission Meeting Schedule
Our meetings will be from 1:30 – 2:30 pm on the following Sunday Afternoons.
We will be meeting in the middle school room, room 113.
*If you miss more than one meeting, you will have to have a meeting with Pastors Jenny and/or
Shenan. We consider our meeting times very important and an important part of the whole
mission’s trip process.
Mission Meeting Dates
Sunday January 10th: First missions meeting – please be here. A LOT of
information is handed out at this meeting.
Sunday March 6th: Team Building and information
Sunday May 1: Team Building and information
Sunday June 19: Mandatory Meeting: This is our last meeting, parents and teens
both must attend this meeting. It will be a short meeting for last minute questions and details.
Payment Schedule Guatemala 2016
Here is your payment schedule:
Payment Schedule
Sunday, December 13: $75 deposit due
Sunday March 6th: $610 payment due – to cover airfare
Sunday May 1: Final Payment - $765 is due to pay off balance of trip.
**After March 6th – All money paid is non-refundable.**
If you must drop out after the plane ticket is purchased, you will
have a ticket in your name to use for one year. Any money for your
trip raised by group fundraising is non-refundable.
Adult Signature: _________________________________
Date: ___________
Your application will not be considered without this page, so please make sure to
include this with your application. Thank you 