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Global Impact Trip Registration
Trip you are applying for
*
Full Name as it appears on your passport
*
Today's Date
*
MM slash DD slash YYYY
Personal Information
First
*
First
Middle
*
Middle
Last
*
Last
Street Address
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Address Line 2
City
*
State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
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District of Columbia
Florida
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Tennessee
Texas
Utah
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Wisconsin
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Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Zip Code
*
Home Phone
Work Phone
Cell Phone
Email
*
Date of Birth
*
MM slash DD slash YYYY
Gender
*
Male
Female
Passport Number
Passport Expiration Date
MM slash DD slash YYYY
2RC Membership
*
Have you completed Wade In?
Member
Non-Member
Insurance Information
Insurance Company
*
Phone Number
*
Group Number
Individual Policy Number
Medical History
Do you have any health issues or allergies that the trip leader should be aware of?
*
Current medications:
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Primary Doctor's Name
First
Last
Last
Phone
Emergency Information
Emergency Contact
*
First
Last
*
Last
Phone
*
Beneficiary Name
*
First
Last
Last
Phone
*
Trip Information
Location and Purpose of Trip
Trip Start Date
MM slash DD slash YYYY
Trip End Date
MM slash DD slash YYYY
Total Trip Cost
Primary Means of Funding This Trip
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Personal Funds
Raise Support from 2RC Friends
Raise Support Outside 2RC
I would like instruction of How to Raise Funds
Service Experience
Do You Serve in the Church?
*
Yes
No
What do you do?
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Leader
*
First
Last
*
Last
Previous Work or Missions Experience
*
Testimony of Faith
*
Why do You Want to Go on This Trip?
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What are Your Expectations of This Trip?
*
Name of a 2RC Pastor Who Recommends You
First
Last
Last
Commitment
I agree to:
Raise Funds as Designated by The Mission Team
Attend Pre-trip Planning Meeting(s)
Send Out a Prayer Letter
Be an Engaged Team Member and Honor the Team Leader
Share my Story Several Places When I Return Home From This Trip
Signature
*
Deposit
Price:
Credit Card
Card Details
Cardholder Name
A $200 Deposit is required to process your application.