Student Application - De Pere ...
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Student Application
STUDENT APPLICATION Due by May 8, 2020
• The trip dates are tentative and may be changed, by a day or two, due to church schedule changes.
• The price for the trip includes: transportation, lodging, meals, and insurance. This is an estimated
amount and could increase due to unexpected lodging fees, parking fees, or other costs of doing
ministry. Personal Spending Money is not included in the price.
• This trip is open to all Destiny Youth and adult sponsors for the trip.
• Because of limited space, applications will be processed on a first come/first serve basis.
Application Checklist
Before turning in your application, be sure to complete the following:
Incomplete applications will be returned and you will be moved to the bottom of the list (space is
limited)
APPLICATION: Make sure you have completed pages 3 & 4 of the application to the best of your ability.
Be sure to include all signatures and your t-shirt size. These two deletions can delay processing.
TESTIMONY/SPIRITUAL INFORMATION: Page 4 of the application requests spiritual information from
you. Please type your testimony and attach on a separate piece of paper.
PHOTO: Attach a current passport type photo of applicant. It is always a good idea for the trip leader to
have a current picture of all students on the trip in case of emergency.
WITNESSES: Pages 6 - 9 must be signed by a parent or legal guardian with two witnesses.
$25 DEPOSIT: The deposit check can be a personal check. Please make all checks payable to ‘Destiny
Church’ and write the student’s name and “Detroit 2020” on the memo line; the $25 will be applied to the
balance of the trip cost. The deposit is non-refundable, unless Applicant is declined.
$75 TOTAL*: The total cost for the trip is $75. This can be paid at the time of the deposit, or the remainder
can be paid by Sunday, June 7th. Like the deposit, please make all checks payable to ‘Destiny Church’
and write the student’s name and “Detroit 2020” on the memo line.
*payment can be made using a giving envelope and placed in a Sunday offering or in the dropbox.
Accounting Procedures:
• Anyone contributing to your trip should make their check payable to “Destiny Church.”
• Each check should have the student’s and “De Pere 2020” in the memo line.
• It is the Applicant’s responsibility to keep a record of all people who contributed to his/
her trip.
Detroit Student Application 2020 Page 2 of 92020 Student Application
(to be completed by any applicant 17 years or younger)
STUDENT INFORMATION
Legal Name as it appears on your Birth Certificate:
Last ________________________________ First _____________________________ Middle ______________
Name you go by if different from your legal name __________________________________________________
Home Address __________________________________ City _________________ State ___ Zip _________
Home Phone (_____) _______________________ Cell Phone (________) ____________________________
What is your shirt size (adult sizes only)? (Please circle one) S M L XL XXL
Birth date (MM/DD/YYYY) ______/_______/___________ Age _______(as of trip date)
Email address ______________________________________________________________________________
FAMILY INFORMATION
Parent(s) Name _____________________________________________________________________________
Address _________________________________ City _____________________ State _____ Zip __________
Are both parents active in church? _____ Yes _____ No Explain _____________________________________
Phone numbers of Parent(s) you live with: Cell Phone: (_____) ________________________________________
Day Phone (_____) _____________________________ Evening Phone (_____) _________________________
REFERENCE INFORMATION
Pastor _____________________________________ Church Name __________________________________
Address_________________________________ City ___________________ State _____ Zip _____________
Phone (_________) ________________________ How long acquainted? _______________________________
EDUCATION INFORMATION
1. What year of schooling are you in? _________________________ __________________________________
2. Special awards and honors _________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
3. Special skills, abilities, or musical talents________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
HEALTH INFORMATION
1. What type of health are you in? ____ Excellent ____ Good ____Fair ____ Poor
Explain _____________________________________________________________________________
2. Is there any history of emotional, mental or physical handicaps? ___ Yes ___ No
If "YES" explain _______________________________________________________________________
3. Do you use alcohol, tobacco, or illegal drugs? ___ Yes ___ No
If "YES" Explain ________________________________________________________________________
Detroit Student Application 2020 Page 3 of 9MISCELLANEOUS INFORMATION
1. Will you be willing and able to eat whatever food you are served? ___ Yes ___ No
If no, please explain your diet requirements __________________________________________________
_____________________________________________________________________________________
SPIRITUAL INFORMATION
Please use a separate sheet of paper and type a brief account, no more than 2 pages of the following:
1. Your spiritual experience
A. Salvation, water baptism, and in-filling of the Holy Spirit. Relate how, when and where for each.
B. Tell us about your present involvement in your church: How long you have attended? Your faithfulness
to Destiny activities? Do you tithe, give to missions (Impact, BGMC, S.T.L.), etc.?
C. Tell us about your spiritual walk: where you are now, where you are going, when and how you share
your faith in Jesus Christ with others, etc.
D. How often do you read your Bible and pray during an average week?
E. What method of Bible study are you now using?
F. Do you feel a calling on your life? If so, what is it?
2. Your experience in Christian work
A. What have you done: when, where, and with whom have you worked.
B. List particular examples of leadership experience.
C. List anything else you feel we should know about you.
3. In a paragraph list your reasons for wanting to participate in this outreach.
Be sure ALL FORMS are complete and turn them into the church office. If you are mailing in your
application send it to:
Destiny Church
Attention Missions Department
411 Destiny Drive
DePere, WI 54115
If you have any questions regarding the trip
or this application, please call (920) 336-7910
ATTACH A CURRENT
PASSPORT TYPE
PHOTO HERE
Detroit Student Application 2020 Page 4 of 9PARENT CONSENT FORM
Parents and legal guardians of minor children are asked to complete this form. The information requested is designed to
assist the church in providing for the safety of minors during church-sponsored activities.
General and Certification
Minor’s Name___________________________________________ Date of Birth _____/_____/_____
Father’s Name_______________________________ Mother’s Name_______________________________
Minor’s Address__________________________________________________________________________
Home Phone No. (_____)__________________ Parent’s Work Phone No. (_____)_______________
Family Doctor___________________________________ Dr. Phone No. (_____)________________
Insurance Company Covering Child_________________________ Policy No.___________________
Consent and Certification
We, the undersigned, being the parents or legal guardians of the child named above (the “minor”), do hereby
consent to the participation of our minor child in Destiny Church’s missions trip to De Pere in 2020, including
the activities of swimming, boating, hiking, sports events, and any other activities customarily associated with a
missions trip. Further, we certify that our child is physically able, and adequately trained, to participate in such
events, including swimming.
We DO NOT authorize our child to participate in any of the following activities (please list):
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Medical Questionnaire
1. Is your child presently being treated for an injury or sickness or taking any form of medication for any reason?
Yes_____ No______ (if yes, please explain) ________________________________________________
2. Is your child allergic to any type of medication?
Yes____ No____ (if yes, please explain) ___________________________________________________
3. Does your child medically require a special diet?
Yes_____ No____ (if yes, please explain) __________________________________________________
4. Does your child have (or has ever had) any of the following: (circle, and explain below)
Seizure disorders Asthma Heart murmur Diabetes Hay Fever Kidney disease
____________________________________________________________________________________
____________________________________________________________________________________
5. Does your child have any allergies other than medical?
Yes____ No____ (if yes, please explain) ___________________________________________________
6. Does your child ever sleep walk? Yes_____ No_____
7. Can your child swim? Yes_____ No_____
8. Does your child have any physical condition or illness, which would prevent him/her from participating in
normal rigorous activity?
Yes_____ No_____ (if yes, please explain) _________________________________________________
Detroit Student Application 2020 Page 5 of 9If your child will need medication on the trip, please fill out page 6 as well.
Medication Distribution Authorization
(To be filled out only if student will need any kind of medication on the trip)
This form must be completed fully for the trip leaders to administer the required medication. A new medication
administration form must be completed for each medication needed during the trip (please make copies of this form if
necessary).
* Prescription medication must be in a container labeled by the pharmacist or prescriber.
* Non-prescription medication must be in the original container with the label intact.
* All medications (Non-prescription or Prescription) must be turned in to Pastor Ben
PRESCRIBER’S AUTHORIZATION
Name of Student: ___________________________________ Date of Birth: ___________________________
Condition for which medication is being administered: ______________________________________________________
Medication Name: ____________________________________Dose: ___________________Route: ________________
Time/frequency of administration: ________________________________________ If PRN, frequency: ______________
If PRN, for what symptoms: __________________________________________________________________________
Relevant side effects: □ None expected □ Specify: ________________________________________________________
Prescriber’s Name/Title:__________________________________________________________
Prescriber’s Telephone: _______________________FAX: _____________________
Address:___________________________________________________
___________________________________________________
Prescriber’s Signature: ____________________________________Date:___________________
PARENT/GUARDIAN AUTHORIZATION
I/We request Pastor Ben to administer the medication as prescribed by the above prescriber. I/We certify that I/we have
legal authority to consent to medical treatment for the student named above, including the administration of medication
during the 2020 missions trip to Detroit. I/We understand that at the end of the missions trip, an adult must pick up the
medication, otherwise it will be discarded. I/We authorize Pastor Ben to communicate with the health care provider if
necessary.
Parent/Guardian Signature: ____________________________________________________ Date: _________________
Home Phone #: __________________ Cell Phone #: ____________________ Work Phone #: ____________________
SELF CARRY/SELF ADMINISTRATION OF EMERGENCY MEDICATION AUTHORIZATION/APPROVAL
Self carry/self administration of emergency medication may be authorized by the prescriber and must be approved by
Pastor Ben two weeks before the trip.
Prescriber’s authorization for self carry/self administration of emergency medication: _____________________________
Signature Date
Pastor Ben’s approval for self carry/self administration of emergency medication: ________________________________
Detroit Student Application 2020 Page 6 of 9Signature Date
Medical Treatment Authorization
We understand that we will be notified in the case of a medical emergency involving our child. However, in the event that
we, or either of us, cannot be reached, we authorize the calling of a doctor and the providing of necessary medical
services in the event our child is injured or becomes ill. We authorize any adult leader participating on this trip or the staff
personal of Destiny Church to make emergency medical care decisions on behalf of our child, if required by law or a
health care provider. We understand that Destiny Church, or any of their agents, employees, or volunteers, will not be
responsible for medical expenses incurred on the basis of this authorization.
We agree to notify the church in the event of any health changes, which would restrict our child’s participation in any
activities. We also understand that the adult church representatives reserve the right to restrict our child from any activity
that they do not feel is within the physical capabilities of my child.
Emergency Contact Information
Parent Phone Number: (________) ________-____________
Parent Cell Number: (________) ________-____________
Health Insurance Co & Policy #
________________________________________________________________
Emergency contact (other than parent) ____________________________________________
Relationship to Student:
__________________________________________________________________
Emergency contact phone number: (________) ________-____________
I HAVE CAREFULLY READ THE FORGOING MEDICAL TREATMENT AUTHORIZATION AND
UNDERSTAND IT’S CONTENTS, AND I VOLUNTARILY SIGN THIS RELEASE AS MY OWN FREE ACT.
THIS IS A LEGAL DOCUMENT AND I UNDERSTAND THAT I HAVE THE OPPORTUNITY TO CONSULT
WITH AN ATTORNEY BEFORE SIGNING IT.
Date (mm/dd/yyyy)_______________________ Signature ________________________________________
Address _________________________________________________________________________________
City ________________________________ State ____________________ Zip ______________
IMPORTANT: Please have 2 witnesses observe your signature, and have them sign below. They must be at
least 18, and should not be relatives.
Witness ________________________________ Witness ________________________________
Address ________________________________ Address ________________________________
City ___________________________________ City ___________________________________
State & Zip ______________________________ State & Zip ______________________________
Detroit Student Application 2020 Page 7 of 9Destiny Church Missions Travel Consent Form
(Required by all applicants under the age of 18)
I ___________________________________ the parent or legal guardian of
___________________________________ give my son/daughter permission to travel with Destiny
Church and/or staff from Aug 7-14, 2020 (dates subject to change as described on page 2 of this
form)
I HAVE CAREFULLY READ THE FORGOING TRAVEL CONSENT FORM AND UNDERSTAND IT’S
CONTENTS, AND I VOLUNTARILY SIGN THIS RELEASE AS MY OWN FREE ACT. THIS IS A LEGAL
DOCUMENT AND I UNDERSTAND THAT I HAVE THE OPPORTUNITY TO CONSULT WITH AN ATTORNEY
BEFORE SIGNING IT.
Date (mm/dd/yyyy)_______________________ Signature ________________________________________
Address _________________________________________________________________________________
City ________________________________ State ____________________ Zip ______________
IMPORTANT: Please have 2 witnesses observe your signature, and have them sign below. They must be at
least 18, and should not be relatives.
Witness ________________________________ Witness ________________________________
Address ________________________________ Address ________________________________
City ___________________________________ City ___________________________________
State & Zip ______________________________ State & Zip ______________________________
Detroit Student Application 2020 Page 8 of 9Media Release Form for Minors I ____________________________________________ the parent or legal guardian of __________________________________________________ give my son/daughter permission to be recorded on different medias for future use in promotions, services, website, and publications of Destiny Church and/or it’s Youth Ministry. I HAVE CAREFULLY READ THE FORGOING MEDIA RELEASE FORM AND UNDERSTAND IT’S CONTENTS, AND I VOLUNTARILY SIGN THIS RELEASE AS MY OWN FREE ACT. THIS IS A LEGAL DOCUMENT AND I UNDERSTAND THAT I HAVE THE OPPORTUNITY TO CONSULT WITH AN ATTORNEY BEFORE SIGNING IT. Date (mm/dd/yyyy)_______________________ Signature ________________________________________ Address _________________________________________________________________________________ City ________________________________ State ____________________ Zip ______________ IMPORTANT: Please have 2 witnesses observe your signature, and have them sign below. They must be at least 18, and should not be relatives. Witness ________________________________ Witness ________________________________ Address ________________________________ Address ________________________________ City ___________________________________ City ___________________________________ State & Zip ______________________________ State & Zip ______________________________ Detroit Student Application 2020 Page 9 of 9
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