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2007 Cambodia Mission Trip Sign Up Form - Paradyme Cambodia

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					    2007 Paradyme Cambodia Mission Trip Registration

PARADYME CAMBODIA MISSION TRIP REGISTRATION             Error! Bookmark not
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 STUDENT INFORMATION                                    2

 PASSPORT INFORMATION                                   2

 T-SHIRT                                                2

 PARENT INFORMATION                                     2

 EMERGENCY CONTACT INFORMATION                          2

 MEDICAL INFORMATION                                    3

 MEDICAL INSURANCE                                      3

 TRIP OPTIONS AND COSTS                                 3

TIC/PARADYME CAMBODIA MISSION TRIP HEALTH FORM          3

 PAST HEALT HISTORY                                     4

 ALLERGIES                                              4

 MALARIA PREVENTION                                     3

 CURRENT HEALTH                                         4

 CONSENT – TO BE COMPLETED BY PARENTS OF YOUTH          5

 CONSENT – ADULTS                                       5

PARADYME CAMBODIA MISSION TRIP PARENT PERMISSION FORM   Error! Bookmark not
defined.6

 PERMISSION                                             6

 QUESTIONS                                              6

ADDITIONAL INFORMATION                                  7

 UPDATES AND INFORMATION AT WWW.PARADYMEYOUTH.ORG       7

 GOALS FOR MISSION TRIP                                 7

 WHAT TO BRING                                          7

 WHAT TO LEAVE AT HOME                                  7

 EXPECTED CONDUCT                                       7




                                    Page 1 of 7
      2007 Paradyme Cambodia Mission Trip Registration
           STUDENT INFORMATION
Student’s First and Last Name:


Date of Birth:                     Gender         M     F            School:               Grade:


Street Address:                                               Home Phone:


Mailing Address:                                              Cell Phone:


Email address:



  PASSPORT INFORMATION
Full name as it appears on Passport:                                 Passport #:


Country:                           Expiry Date:                      Issuing Agency:




  T-SHIRT
Mark the size of T-shirt you want (note these are Taiwanese Sizes)

M                     L                      XL                 XXL          XXXL

  PARENT INFORMATION
Parent’s First and Last Name:


Email address:                                                Cell Phone:


Occupation:                        Employer:                  Work Phone




  EMERGENCY CONTACT INFORMATION # 1
Name:


Phone:


Mobile Phone:


Relationship to Student:



  EMERGENCY CONTACT INFORMATION # 2
Name:

                                                       Page 2 of 7
      2007 Paradyme Cambodia Mission Trip Registration
Phone:


Mobile Phone:


Relationship to Student:



  MEDICAL INFORMATION
Please fill out and return the Tic/Paradyme Cambodia Mission Trip Health Form with this form.

MALARIA PREVENTION
Most travel sites recommend protection for Malaria when traveling in Cambodia. During this mission trip we
will be traveling in Northwest Cambodia near the Thailand border. Because of this, we are providing
doxcycline for all mission trip participants. If you do not wish your child to take doxcycline or are making
other arrangements, please contact Pastor Doug.

Read the following:

I understand Cambodia is listed as an at risk country for Malaria. It is recommended participants take
anitmalarial Medicine for prevention. The Centers for Disease Control and Prevention Center recommends
atovaquone/proguanil or doxycycline as the antimalarial drug for travelers to Cambodia. (Information:
http://www.cdc.gov/travel/regionalmalaria/seasia.htm).

Check and Initial one of the following choices:

        TIC should plan to provide doxycycline for my child as the antimalarial medicine. ___________

        I will consult with a doctor and obtain the appropriate antimalarial drug for my child. ___________

        Send me more information on antimalarial drugs and how to obtain them. ___________



Most travel sites recommend protection for Malaria when traveling in Northwest Cambodia. Because of this,
we are providing doxcycline for all mission trip participants

  MEDICAL INSURANCE
Travel insurance for each participant is included. However, if you do not have medical coverage in
Cambodia, it is strongly recommended that you take out additional insurance.




  TRIP OPTIONS AND COSTS
The cost is 20,000 NTD. Actual cost should be lower and excess funds will go towards New Hope for
Orphans Needs and/or construction costs. Please mark the trips you want to participate in.

    June 11-21, 2007 Mission Trip

    June 8-10, 2007 Youth Retreat (add 2,000 NTD)

    Optional Angkor Wat Visit – (add USD 25 or 825 NTD)




                                                   Page 3 of 7
    2007 Paradyme Cambodia Mission Trip Registration
    TIC/PARADYME CAMBODIA MISSION TRIP HEALTH FORM
 Private And Confidential: The Health Information Will Only Be Viewed By The Trip Nurse And Pastor Doug

                    YOUTH – PLEASE HAVE YOUR PARENTS COMPLETE THIS FORM



NAME: _____________________________________

AGE GRP: 12-13 14-15 16-17 18-19 20-25 26-30 31-35 36-40 41-45 46-50 50+



  PAST HEALT HISTORY
Please circle if you have or have had any of the following:

Asthma     Diabetes     Epilepsy/convulsions       Hearing problems        Heart problems

High blood pressure      Kidney/Urinary problems        frequent headaches/stomach-aches



Have you had any serious illness, injury or operation? ______ If yes, please describe




  ALLERGIES
Do you have any allergies? ______ If yes, what to? ______________________________

         What is the reaction? ____________________________________________________

         Treatment? ____________________________________________________________

         Do you carry this medication with you? _______________________________________



  CURRENT HEALTH
Do you have any current health problems? ______ If yes, please describe



Are you currently taking any medications? ______ If yes, please list drug, dose, frequency



Are you able to participate in the full range of activities anticipated on this trip? ________

         If no, please list exceptions _______________________________________________



Are you fully immunized according to local/home country standards? _________

When was your last tetanus booster? ________________________________

It is also recommended that you have had vaccinations for Hepatitis A and Typhoid.

         Please note that Typhoid vaccination is not readily available in Taiwan.

                                                   Page 4 of 7
    2007 Paradyme Cambodia Mission Trip Registration
  CONSENT – YOUTH                   To Be Completed By Parents Of Youth
Do you consent to your youth: PLEASE INITIAL

Receiving minor first aid by the nurse? _______

Being given over the counter medications such as paracetamol/acetaminophen for headache, pain, fever, or
an antacid (e.g. Mylanta, Tums) for upset stomach? _______

Signature of parent ________________________________ Date _______________

Should you be unavailable in the event of an accident or emergency, do you give permission for Pastor Doug
Street and/or trip Nurse to act “in locus parentis” (in place of parents) and to transport your child to the
nearest hospital for urgent treatment (which could include surgical intervention under anaesthesia) as
deemed necessary by appropriately qualified hospital staff. I understand that expenses incurred are the
responsibility of the parents. _______

Signature of parent ________________________________ Date _______________

  CONSENT – ADULTS
Please give details of every possible way of contacting next of kin


     Next of Kin



        Phone



    Mobile Phone:




Should next of kin be uncontactable in the event of an accident or emergency, do you give permission for
Pastor Doug Street and/or Nurse Sue Platell to transport you to the nearest hospital for urgent treatment
(which could include surgical intervention under anesthesia) as deemed necessary by appropriately qualified
hospital staff. I understand that expenses incurred are my responsibility. _______ (initial)

Signature ___________________________________ Date ___________________




                                                  Page 5 of 7
    2007 Paradyme Cambodia Mission Trip Registration
  PERMISSION FORM
Please read each statement and check the boxes before signing

      I consent to (student’s name) _______________________________________ participation in the
       Paradyme Youth Mission Trip to Cambodia in the summer of 2007.

      I understand accidents my happen and agree not to hold Taipei International Church or it’s
       representatives responsible, and that I am responsible for insurance for my youth.

      I have read the information available and understand the work and living conditions for the mission
       trip.

      I also agree to attend a mandatory parent/youth meeting on Sunday, May 27 to go over any rules,
       emergency procedures, travel information, etc. for the event.

      I am aware of the risk of Malaria in Cambodia and will take appropriate precautions.

      I have checked my son/daughter’s passport and it is does not expire before January 31, 2008

      I understand some training and orientation will be required on Sunday afternoons and evenings in
       May.

      Payment Schedule: The minimum payment schedule for all trip is as follows.

               May 13, 2007    10,000 NT

               May 27, 2007    Balance Due

      If you are in need of a scholarship, please contact Pastor Doug at doug@paradymeyouth.org. All
       requests and grants of scholarships remain confidential.



Signed (parent or legal guardian) _______________________________________ Date: _______________



  QUESTIONS
Please write any questions or comment you may have here.




                                                Page 6 of 7
      2007 Paradyme Cambodia Mission Trip Registration
                                   ADDITIONAL INFORMATION
     UPDATES AND INFORMATION AT www.paradymeyouth.org
Rules for the trip will be given out at the mission trip meeting on Sunday, May 27, 2007. Here are a few
general guidelines.

     GOALS FOR MISSION TRIP
Help students …

            discover and/or develop the joy of serving others.

            increase awareness of the plight of less fortunate people – both physically and spiritually.

            discover gifts they may have and that God wants and will use them.

            learn that ministry is participation not just passive observation.

            show the love of God to the Cambodian people.

     WHAT TO BRING
1.    Hat                                                          6.   toiletries – shower stuff

2.    Towels, soap                                                 7.   Spending money

3.    work clothes – including tennis shoes or work                8.   Bible
      shoes
                                                                   9.   extra clothes you may want to give away
4.    sun block
                                                                   10. at least one long sleeve shirt and pants
5.    Mosquito repellant
                                                                   11. Work gloves (Canvas or leather will last longer)

     WHAT TO LEAVE AT HOME
1.    Alcohol, drugs – stuff not appropriate for youth group

2.    Recommend you leave cell phone, mp3 players, etc at home. The only time you will be able to use them is
      on the plane, and they will not be safe in the hotel rooms. There will not be electricity available for charging
      batteries at the Orphanages.

3.    Most of Cambodia now how cell phone coverage.

     EXPECTED CONDUCT
Respect others

Have a good attitude – if you need to complain, then complain to Pastor Doug

Make wise choices

Be on Time:




                                                       Page 7 of 7

				
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