High School Mission Trip to Pine Ridge, SD

Please complete this information for the student registering for the mission trip week. List grade for the 2025-2026 school year. Email listed on this form will receive confirmation email for registration.

Name

This address will receive a confirmation email

Phone

Address

Grade

Medical / Allergy Concerns

Emergency Contact Information -- please list those who should be contacted in case of emergency during this mission trip.

Emergency Contact #1 Name / Phone

Emergency Contact #2 Name / Phone

Parent / Guardian Information -- if different from Emergency Contact listed above

Parent(s) / Guardians(s) Name(s) & Phone Numbers

Permissions --

Events may be photographed or videoed for publicity purposes and may be posted on the Gloria Dei website and/or social media platforms. Please contact Gloria Dei to opt out.

I give permission for my child to attend and participate in the above event sponsored by Gloria Dei Lutheran Church. In the event that I am not immediately available for consultation in an emergency, I authorize an adult, in whose care my child has been entrusted, to consent to any X-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment, and hospital care, to be rendered to my child under the general or special supervision and on the advice of any licensed physician or dentist on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital. I shall be liable and agree to pay all costs and expenses incurred in connection with such medical and dental services rendered to my child pursuant to this authorization.

Yes No

PARENT GUARDIAN -- Typing my name here acknowledges my electronic signature (required).

Payment --
To pay online select 'Deposit' or 'Full Payment'. Online payment includes transactions fees.
To bring / mail check or cash to Gloria Dei select 'Bring Payment to Gloria Dei.' In-person payments are $150

Payment

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

High School Mission Trip to Pine Ridge, SD | April 17 - 19

Description

High School Mission Trip to Pine Ridge, SD | April 17 - 19

Description

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