GO, LOVE, SERVE, U.S.A. Please enable JavaScript in your browser to complete this form.Name *FirstLastIf you are under the age of 18, please have a parent or legal guardian complete and sign this form. Thank you.Mobile Phone Number *Email *Address *Address Line 1Address Line 2CityState / Province / RegionPostal Code--- Select country ---AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Republic of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountryBirthdate *T-Shirts are $15. Do you want one?YesNoYour T-Shirt Size *SmallMediumLargeXL2X3X4XI don't want a shirtDo you plan to stay on the Place of Grace Campus? *YesNoNOTE: If you plan to stay on campus, please bring either twin bedding or a sleeping bag and pillow. And, please consider a love offering for the Place of Grace also.Emergency Contact InformationPlease enter the name of the person who should be contacted in the case of an emergency.Name *FirstLastRelationship *SpouseParentSiblingRelativeFriendE-mail *Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone *Questions or CommentsRelease and Waiver of LiabilityI, the undersigned participant, hereby acknowledge that I am a legal adult and agree that my participation in the GO, LOVE, SERVE Trip organized by CHC World Missions and Place of Grace is entirely voluntary. In consideration of being allowed to participate in this trip, I hereby agree to the following terms and conditions: Assumption of Risk I understand that participating in the GO, LOVE, SERVE Trip involves inherent risks and dangers, including but not limited to travel risks, physical activities, potential exposure to illness, and various environmental conditions. I hereby assume all risks associated with my participation in this trip. Release of Liability I hereby release, waive, and discharge CHC World Missions, Place of Grace, their officers, directors, employees, agents, volunteers, and any other representatives from any and all liability, claims, demands, actions, or causes of action arising out of or related to any loss, damage, injury, or harm of any kind, including death, that may occur during my participation in the GO, LOVE, SERVE Trip. Indemnification I agree to indemnify and hold harmless CHC World Missions, Place of Grace, their officers, directors, employees, agents, volunteers, and any other representatives from any and all claims, demands, actions, or causes of action, including attorney’s fees and costs, arising out of or related to my participation in the GO, LOVE, SERVE Trip. Medical Treatment I consent to receive medical treatment deemed necessary if I am injured or become ill during the trip. I understand and agree that I am solely responsible for all costs related to such medical treatment, including transportation expenses. Personal Responsibility I understand that it is my responsibility to ensure my own safety and well-being during the trip. I agree to follow all instructions and guidelines provided by trip leaders and to act in a manner that is respectful and considerate of others and the environment. Binding Effect This Release and Waiver of Liability shall be binding upon me, my heirs, executors, administrators, and assigns, and shall inure to the benefit of CHC World Missions and Place of Grace and their respective successors and assigns. I HAVE READ THIS RELEASE AND WAIVER OF LIABILITY, FULLY UNDERSTAND ITS TERMS, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.Signature * Clear Signature Submit