Mission Trip 2023 - East Bank, WV

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Student Name

*

Student Phone

*

Student Date of Birth

*

Student Grade

*

Please select one option.

8 9 10 11 12

Student Mailing Address

*

Parent Name

*

Parent Phone

*

Parent Email

*

This address will receive a confirmation email

I would like to receive mission trip updates by

*

Please select all that apply.

Text Email Mail

I am interested in attending the trip as an adult leader.

*

Please select all that apply.

Yes No

Deposit

Credit Card ($50.00) Cash/Check ($0.00)

Amount

Credit/Debit Card Number

Expiration Date/CVC

Name on Card

Card Billing Address

Description

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