Name - Main Point Of Contact *

First Name

Last Name

Phone *

(###)

###

####

Date of Birth *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Name

(Second Family Member)

First Name

Last Name

Phone

(###)

###

####

Name

(Third Family Member)

First Name

Last Name

Phone

(###)

###

####

Name

(Fourth Family Member)

First Name

Last Name

Phone

(###)

###

####

Name 1

First Name

Last Name

Phone 1 *

(###)

###

####

Treatments *

Has the participant ever been treated by a doctor for any of the following? Check all that apply.

Major Dental Problems

Skin Problems (non acne)

Hearing Problems

Vision Problems

Cysts, Tumors or Growths

Bone or Joint Problems

Back Problems

Emotional Problems

Disabilities

Frequent Ear Infections

Convulsions or Seizures

Heart Defects or Heart Disease

Bleeding or Clotting Problems

High or Low Blood Pressure

Hernia

Diabetes or Hypoglycemia

Asthma or Breathing Problems

Eating Disorders

Dizzy Spells or Migraines

Diarrhea or Constipation

N/A

Other

Diseases *

Has the applicant ever been treated by a doctor for any of the following diseases? Check all that apply.

Parkinson's Disease

HIV/AIDS

Tuberculosis

Cancer

Hepatitis

Other Diseases

N/A

Other

Allergies *

Does the applicant struggle with any of the following allergies? Check all that apply.

Insect Stings

Food Allergies

Drug or Medical Allergies

Poison Ivy

Pollen

Other Allergies

N/A

Other

Physician Phone *

(###)

###

####

Name of Policy Holder

First Name

Last Name

I will make every effort to meet the deadlines for turning in my money and know that I may be removed from the team if this is not fulfilled. (All money turned in is non-refundable.) *

I/We commit

As a team member, I will work under the leadership of Joey Potter Missions, JPM Staff and my team leaders; following the behavioral, spiritual, and safety guidelines that are given to our team. *

I/We commit

I will not complain during the trip and/or cause dissension. *

I/We commit

I understand that I am not to pursue any romantic interest or develop any “special relationship” during this trip (be physical with this person in any way). Should I become interested in anyone during the trip, I understand that I may tell a team leader about this interest if I so choose, but that I may not discuss it with this person or with any other participant during the trip. *

I/We commit

I will follow the team’s and the culture’s dress codes. *

I/We commit

I will be sensitive to the practices, food, and living situations of the culture that I am visiting and I will not criticize or complain. *

I/We commit

I understand that I may be sent back to the U.S. at my own expense if I’m unable or unwilling to meet the above conditions. *

I/We commit

I commit to completing the required training videos, reading material and Enneagram test to come after submitting this application. *

I/We commit

Participant Electronic Signature *

The electronic entering of your first and last name below acts as your electronic signature.

First Name

Last Name

Today's Date *

MM

DD

YYYY

Parent/Guardian Electronic Signaure

(If applicable)

First Name

Last Name

Today's Date *

MM

DD

YYYY

I do understand the risks involved in participating in a trip with JPM Missions Projects. I assume full responsibility for myself, or my child if a minor, for any and all risks. *

I/We understand

I understand Joey Potter Missions reserves the right to refuse any person it judges to be incapable of meeting the rigors and requirements of participating in its activities. I therefore certify that the medical and health information I have provided on this form is true and accurate to the best of my knowledge. I, or my child if a minor, am/is in good physical condition and therefore fully capable of participating in and able to undertake all of the activities involved in a JPM experience. I, or my child if a minor, do/does not have any medical condition that would prevent my, or his/her, participation except for those restrictions listed in Section D of this form. *

I/We understand

I, or my child if a minor, agree not to use alcohol or illegal drugs while participating in JPM. I also assume full financial responsibility for any physical damage to persons or property caused by myself, or my child if a minor. *

I/We understand

I hereby authorize and release to JPM the use of my image, or my child’s if a minor, in a video recording or photograph for any purpose of Joey Potter Missions Projects. *

I/We authorize

I hereby give permission for any qualified medical personnel to render necessary emergency medical care for myself, or for my child if a minor. I also give said personnel the permission to make any necessary judgment decisions. I certify that I have adequate health, disability, and life insurance for myself, or for my child if a minor. *

I/We authorize

I agree that, should there be an issue or dispute as to the validity of any release that I have signed, this document shall supersede any other document that I have read and signed about my legal rights concerning Joey Potter Missions. I also understand that the terms of this agreement shall continue to be in effect even after the trip has ended. *

I/We agree

Therefore I, *

First Name

Last Name

of my own free will, for my family, my children who are minors, my heirs and executors, and myself, have read, understand, and acknowledge the risks and liability for myself and my family on this day. *

MM

DD

YYYY

Participant Electronic Signature *

First Name

Last Name

Parent/Guardian Electronic Signature

If participant is a minor.

First Name

Last Name

Hotel Booking

This year all Gatlinburg participants will be staying at the same hotel and rooms will be booked through JPM. Only ONE person in your party/family needs to complete the room information.

I will complete the room information below

Someone else in my family/group has completed the room information for me.

Please check below how many rooms you will need

1 ROOM

2 ROOMS

3 ROOMS

MORE THAN 3 ROOMS

Please check all of the nights you will need these rooms:

(If you need a different combination of nights and rooms please email Hannah Beth directly at hannahbeth@joeypottermissions.org)

THURSDAY NIGHT

FRIDAY NIGHT

SATURDAY NIGHT

I am traveling alone and would like more info on sharing a room with another participant

Check here if you would like to purchase a sweatshirt with your registration for $45

YES