JPUSA Service Learning Trip
Please fill out this form and click submit.
Name
*
Age During Trip
*
Date of Birth
*
Email
*
This address will receive a confirmation email
Cell Phone
*
Do you check your email weekly?
*
Please select all that apply.
Yes
No
Is there any existing medical situation or physical condition that affects your mobility or restricts you from physical exertion?
*
Please select all that apply.
Yes
No
My overall physical condition is:
*
Please select all that apply.
Excellent
Good
Fair
Poor
Emergency contact & phone number (someone not on trip)
*
Allergies/medical details that the leader will need to know:
*
List any family/friends who are also applying:
*
How do you serve at Covenant, in your community, and in your household?
*
What are you curious about as we participate in this service learning opportunity together? What would you like to learn?
*
What questions do you have for God on this trip?
*
How would you like to grow in your faith and participation in the Gospel through this trip?
*
Payment
Pay in Full ($260)
Pay half. I will pay the other half by May 15 ($130)
Pay in Full ($260)
Pay half. I will pay the other half by May 15 ($130)
Amount
Credit/Debit Card Number
Expiration Date/CVC
Name on Card
Card Billing Address
AA
AB
AE
AK
AL
AP
AR
AS
AZ
BC
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MH
MI
MN
MO
MP
MS
MT
NB
NC
ND
NE
NH
NJ
NL
NM
NS
NT
NU
NV
NY
OH
OK
ON
OR
PA
PE
PR
PW
QC
RI
SC
SD
SK
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
YT
Submit
Description
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