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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. ___________________________ ______________________________ ___________________________ ______________________________ 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:____________________________________________________