Download Journey of the Heart Trip 2006

Journey of the Heart
Trip 2017
I understand the commitment required and have reviewed the information provided
concerning the 2017 Journey of the Heart trip. I understand that the trip to Pine Ridge,
South Dakota, will take place the week of July 8-15, 2017. The group will depart on
Saturday, July 8, and return the following Saturday, July 15.
In making this commitment, “Journey of the Heart” will be paying a fee of $279 to the
sponsoring organization “Youthworks.” This fee is non-refundable after 12/1/16.
To reserve a spot for this mission experience, I agree to pay a $100.00 deposit that will be
returned to me upon successfully raising the necessary $700 needed to cover my portion of
the trip. In the event I do not raise the necessary funds, my deposit will be applied to my
account and I will be responsible for the remaining balance. This deposit will be held in
the Journey of the Heart bank account.
By signing this commitment, I agree that in the event I decide not to participate in the
2017 trip, I must cancel my spot by December 1, 2016. If I cancel after this date, I will
forfeit my deposit and agree to reimburse the Journey of the Heart program the remaining
balance of the fee paid of $179.00.
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Student (print)
Parent or Guardian (print)
Student Signature
Parent or Guardian Signature
Return Completed form and deposit to: Cathie Truehl in Parish Office
Do not write below this line
Deposit amount:_______________________________
Deposit Date:_________________________________
Check Number: ________________________________
STUDENT / FAMILY INFORMATION SHEET
PARTICIPANT’S NAME:________________________________________________________
BIRTH DATE: _______________________________________
GRADE STUDENT COMPLETING MAY 2017; (circle)
8
SEX; (circle)
9
10
11
M
F
12
FATHER /GUARDIAN’S NAME __________________________________________________
MOTHER /GUARDIAN’S NAME__________________________________________________
HOME ADDRESS_____________________________________________________________
CITY, ZIP____________________________________________________________________
HOME PHONE: ____________________________________
CELL PHONE ____________________________ belongs to __________________________
CELL PHONE ____________________________ belongs to __________________________
CELL PHONE ____________________________ belongs to __________________________
PARENT EMAIL ADDRESS:_____________________________________________________
ADDITIONAL EMAIL ADDRESS(S)
___________________________________________belongs to ________________________
___________________________________________belongs to ________________________
STUDENT EMAIL ADDRESS:____________________________________________________