Summer Service Trip Application 2018 Service Trip to Detroit, MI Dates: June 24 June 30, 2018 Section One: Personal Information First and Last Name School Grade (Fall 2018) 10 11 12 College Freshman Street Address City Teen Phone # Parent Name(s) Parent Phone # Zip Teen Email Parent email T-Shirt Size Section Two: Guidelines and Expectations Please initial to signify that you meet the guidelines and will adhere to the expectations. In the fall of 2018 I will be a sophomore, junior, or senior in high school or a college freshman. I will participate in all group activities. I will attend the two pre-trip meetings. (4/8 4-5:30pm, 5/6 4-5:30pm) I understand that if I don t participate in group fundraising activities, I will not get those funds. I will respect the property we will be using, as well as the property of others. I will not leave the facility and worksite during the trip. I will not bring illegal substances or electronic devices (phone, ipod, games). Alcoholic beverages/drugs of any kind/sex are not allowed, and will not be tolerated. My signature below confirms my agreement with the preceding terms. Applicant Signature Date
Section Three: Applicant Questionnaire 1. How did you hear about the service trip? 2. Please explain briefly why you want to be part of the service trip. Section Four: Parent/Guardian Affidavit and Authorization I give permission for my teen, to attend the service trip sponsored by St. Francis Xavier Parish, during the dates of June 24-30, 2018. I am aware that my teen will travel by bus and stay at St. Frances Cabrini High School in Allen Park, MI and do service in Detroit, MI. I hereby release and indemnify the St. Frances Cabrini High School and Young Neighbors in Action, its staff, the staff and volunteers of St. Francis Xavier Parish, a corporation sole, from any and all liability arising from claims of any kind or nature whatsoever from my child s participation in this program. In the event that I, my spouse, or our authorized physician cannot be reached, and in the judgment of the adult leaders, if there is a necessity for immediate examination and/or treatment of my child, I hereby authorize any of the aforesaid personnel to obtain for my child such medical services as are deemed necessary. I understand that I will be called and asked to pick up my child immediately if he/she does not abide by the rules of the weekend as stated on the reverse. Signature Print Name Physician Date Cell phone Physician phone Medical Insurance Company Policy/ Group Number
Please list below any and all of your child s medical problems, medication, or dietary needs.. Section Five: Cost The total cost of the service trip will be $525 for teens and adult leaders. This cost covers: transportation, all meals, lodging, program supplies, Young Neighbors in Action T-shirt and water bottle, and worksite supplies. Fees also cover program staff, administrative expenses, and supplemental insurance. Group fundraising will be done to help lower this cost. $175 is due at registration to guarantee your spot. There will be a 2 nd payment of $175 due March 1 st and a 3 rd payment of $175 due May 1. Payments are made to: St. Francis Xavier Parish Attn: Olivia Hollman, 124 N Spring Ave, La Grange, IL 60525 ***If cost is the only thing keeping you from joining us, please contact Olivia Hollman at (708) 352-0168 or ohollman@sfxlg.org for scholarship information.
Young Neighbors in Action 2018 Sponsored by the Center for Ministry Development Site Information Form Site: Detroit, MI Date: June 24-30, 2018 Program Location and Mailing Address for cards or letters during the event: St. Francis Cabrini High School Participant Name c/o YNIA use this address for mailing: 9000 Laurence Avenue Allen Park MI 48101 15305 Wick Road Allen Park, MI 48101 Emergency Phone: Please use the cell phone number listed for your site coordinator. Accommodations All participants (including adults) sleep in the high school classrooms with 10-15 participants sharing sleeping space on a carpeted or uncarpeted floor. Participants are advised to bring SINGLE-sized air mattresses or foam pads for more comfortable sleeping, as well as pillows, linens/sleeping bags and towels for personal use. Showers are available on-site. Facility Arrival & Departure Plan to arrive at the YNIA facility between 1 2 pm on Sunday, June 24; the program will end following lunch on Saturday, June 30 approximately 1 pm. Airport Information Detroit Metropolitan Wayne County Airport (DTW) 11 miles, approx. 18-25 minutes to site William Rogell Drive Detroit, MI 48242 http://www.metroairport.com/ Airlines: http://www.metroairport.com/airlines/ Ground Transportation: http://www.metroairport.com/transportation/ Coleman A. Young International Airport (DET) 19 miles, approx. 25 minutes to site 11499 Conner Detroit, MI 48213 (313) 628-2146 http://www.detroitmi.gov/departmentsandagencies/airport/airportinformation.aspx Parish Leader Name: Olivia Hollman Email: ohollman@sfxlg.org Phone: (708) 352-0168 x338 Departure Time from School/Parish: AM June 24 (Exact time TBD) Expected Return time to School / Parish: PM June 30 (Exact time TBD)