Church Directory Information Form

Church Directory Information Form - Downloadable

Download the form above and submit according to the directions.

OR fill out the form below and submit. Your information will be electronically submitted to the presbytery office.

Pilgrimage & Study Trip to Israel-Palestine Application

"*" indicates required fields

Step 1 of 4

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Full Name:*

First Middle Last

Name you prefer to be called (If different than first name):

Address:*

Street Address City State ZIP Code

Preferred Phone:*

Type:*

Cell

Home

Work

Alternate Phone:*

Type:*

Cell

Home

Work

Email:*

Congregation or presbytery of membership:*

City:*

City

Presbytery:

If you are not a member of a Presbyterian congregation, please provide two personal references.

I need to provide references.

References

If you are not a member of a Presbyterian congregation, please provide two personal references.

Reference #1 Name:

First Last

Relationship to you:

Number of Years Known:

Phone

Reference #2 Name:

First Last

Relationship to you:

Number of Years Known:

Phone

Your Role

What best describes you? Please check all that apply.*

Church Member

Ruling Elder

Deacon

Seminary Student

College Student

Teaching Elder

Retired Teaching Elder

Other

Other:*

PASSPORT INFORMATION

Please provide the following information exactly as it is recorded on your passport. Note that you must have a valid passport that expires no sooner that 6 months after the conclusion of the trip.

Passport Number:*

Date Issued:*

MM slash DD slash YYYY

Expiration Date:*

MM slash DD slash YYYY

Gender:*

Male

Female

Please upload a copy of the page in your passport that includes your photo.

Max. file size: 15 MB.

HEALTH AND INSURANCE INFORMATION

All health and insurance information will be kept confidential and used only for the purposes of this trip. All questions in this section are required.

My general health is :*

Excellent

Good

Fair

Other

If other, please explain:

I am a smoker:*

Yes

I have allergies:*

Yes

If yes, please explain:

I have physical restrictions:*

Yes

If yes, please explain:

I have dietary restrictions:*

Yes

If yes, please explain:

Are you currently under a physician’s care/or taking prescription medication?*

Yes

Please list all medications that you will need to have with you on the trip:

Are there any other special considerations we should know about?

Please explain.

Health Insurance Company:

Policy and Group Number:

Hidden

Policy and Group Number:

Policy Holder's Name:

First Last

Insurance Authorization Phone Number:

Optional: Upload a copy of your health insurance card and/or any medical records that you would like us to have in case of emergency.

Drop files here or

Max. file size: 15 MB.

EMERGENCY CONTACT

Please identify a person whom we would contact in the event of an emergency while on the trip.

Full Name:*

First Last

Emergency contact phone number:*

Emergency contact email :*

GETTING TO KNOW YOU

The following questions will help us get to know you as we prepare for this trip.

Please describe aspects of your background that would help us get to know you – your work, interests, family, church involvement (to be shared with other on the trip).*

Have you ever traveled to Israel/Palestine? If so, what motivates you to return? If not, what motivates you to go on this trip?*

The trip involves walking and some hills, provides a nice variety of regional cuisine, and includes simple but comfortable hotel accommodations. Do you have special accommodations or concerns of which we should be aware?**

Yes

If yes, please explain.*

Will you commit to 3 pre-trip Zoom meetings and some reading for orientation?*

Yes

Consent and Release

Consent*

Please read below before signing/submitting, as this constitutes an agreement between yourself and the Presbytery of North Central Iowa, the Presbytery of Prospect Hill, and the Presbytery of Des Moines regarding your participation in this trip:

I acknowledge and state that I have chosen to sign up for and travel on this trip to Israel and Palestine at my own risk.

I certify that I am physically able to participate in this trip. I assume all risk and responsibility as well as related costs and expenses for any damage or injury to my property or any personal injury, which I may sustain while on this trip. I understand that I am responsible for my personal effects and property while on the trip. I will hold the Presbyteries harmless in the event of theft, loss, or injury resulting from any source or cause.

By my submitting this application, I release, discharge, indemnify and forever hold Presbytery of North Central Iowa, the Presbytery of Prospect Hill, the Presbytery of Des Moines, and any other related agency, together with their officers, agents and employee, harmless from any and all causes of action arising from my participation in this trip, including travel or lodging associated therewith, or any damages which may be caused by their own negligence.

I have read and agree to this consent.

Signature*

Date*

MM slash DD slash YYYY

Payment

A $100 deposit is required to save your space on the trip. The total registration fee of $2750 is due by January 15, 2022. If paying by credit card, 3% will be added to cover credit card fees. To pay by check, please make your check payable to United Presbyteries of the Plains and mail it to:
Presbytery Office
1864 Hwy 86
Milford, IA 51351

I am paying by:*

Check

Credit Card/PayPal

Payment Amount

Payment of Deposit - $100

Full Payment - $750

Credit Card Fee:

Price: $0.00

Credit Card Fee:

Price: $0.00

Total