Step 1 of 11 0% What trip are you registering for?*Tepeyec, Costa Rica March 2-9, 2021Cost of Trip*The Cost of the trip is $450.00. Your $450.00 is for your room and board while we are in Costa Rica, and ground transportation. This amount does not include your flights to and from San Jose, Costa Rica or any incidentals you may want to purchase while there or souvenirs. I agree Excess Funds Acknowledgement*RMS has significant experience in estimating trip costs. It does its best to estimate them accurately. However, Participants understand that actual trip costs may end up either slightly higher or lower than our best estimate. Participants further understand and agree that if trip costs are more than estimated, RMS will be responsible for any excess and no excess charges will be passed on to Participants. However, if trip costs are less than estimated, Participants agree that RMS may retain any excess and no refunds will be made. I Agree Name* First Last Nick NameHow do you desire to be addressed during the trip.Gender*MaleFemaleBirthdate* Date Format: MM slash DD slash YYYY Address* Home Address Address Line 2 City State/Province Zip/Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Preferred Phone Number*Other Phone NumberYour Email Address* Enter Email Confirm Email Would you like to receive emails from us about future opportunities? Yes As of today are you a legal adult, over 18 years old?*YesNoBackground Check Information*Beginning March 1, 2017, The Board of Reformed Mission Services has implemented the following policy: “Background checks will be required on everyone 18 years old and over who has direct, personal access to event participants.” To ensure compliance and implementation of this policy, Sponsors, Host Team Coordinators, Volunteers, Committee members, and Students, 18 years of age or older, who will be serving with minors at any RMS event, including TASC, will be required to perform the steps listed below: SPONSORS: Each Sponsor is required to submit information for a Background Check and view a Training Video through the organization “Protect My Ministry”. HOST TEAM COORDINATORS: Each Host Team Coordinator is required to submit information for a Background Check and view a Training Video through the organization “Protect My Ministry”. They shall also be familiar with the RMS Safety, Security and Supervision Policy (see the 2017 TASC Manual Appendix: Safety, Security, and Supervision Policy). VOLUNTEERS AND HOST TEAM COMMITTEE MEMBERS: Each Volunteer, Helper, and Committee Assistant at the Host Church is required to submit information for a Background Check through the organization “Protect My Ministry”. STUDENTS: Each Student who is 18 years of age or older at the time of the event is required to submit information for a Background Check through the organization, “Protect My Ministry”. Protect My Ministry, a third party service, notifies RMS whether applicants pass or fail a background check. We are not notified of any specific details regarding an applicant’s history. You will not be notified by Reformed Mission Services and/or Protect My Ministry unless more information is needed. I Agree Parent/Guardian Name* First Last Parent/Guardian Phone Number*The best number to be able to contact themParent/Guardian Email* Enter Email Confirm Email Emergency Contact #1 Name*A person not attending the trip that we can contact in case of an emergency First Last Emergency Contact #1 Phone Number*Emergency Contact #1 Relationship*FatherMotherSpouseBrotherSisterChildWould you like to add another emergency contact? Yes Emergency Contact #2 Name*A person not attending the trip that we can contact in case of an emergency First Last Emergency Contact #2 Phone Number*Emergency Contact #2 Relationship*FatherMotherSpouseBrotherSisterChildBeneficiary (ex. parent, sibling, spouse)*RMS provides supplemental insurance coverage while you attend RMS events. Please provide the first name and last name of the person you wish to list as the beneficiary. First Last Beneficiary Relationship*FatherMotherSpouseBrotherSisterPassport Number*Please choose one of the following answers regarding your passport number or Enhanced Driver's License (for designated states and countries only). I have a passport or an enhanced driver’s license.I have a passport or enhanced driver’s license, but I do not need to share this information for the trip I am registering for.I do not have a passport or enhanced driver’s license.My Passport or Enhanced Driver's License number is* T-Shirt*What size t-shirt do you wear (adult sizes only)?SmallMediumLargeX-LargeXX-largeXXX-LargeXXXX-LargeWork PreferencesWhat types of work have you done before? Please check all that apply! Painting Demolition Organization Cleaning Carpentry Office Work Food Pantry Construction Concrete Working with Children Landscaping Anything Other Please describe other work preferenceOther SkillsIs there anything you may have professional skills or certificates? Please check all that apply! Doctor Nurse CPR Paramedic Carpenter Plumber Electrician Other Please describe other skill/certificates What is the name of the church you attend:*---Bethany United Reformed Church, Wyoming, MIBethel United Reformed Church, Jenison, MIBurlington United Reformed Church, Burlington, WACloverdale United Reformed Church, Boise, IDCommunity United Reformed Church, Schererville, INCornerstone United Reformed Church, Hudsonville, MICornerstone United Reformed Church, Sanborn, IACovenant Reformed Church, Carbondale, PACovenant Reformed Church, Newton, NJCovenant Reformed Church, Pella, IACovenant United Reformed Church, Kalamazoo, MICovenant United Reformed Church, Pantego, NCDoon United Reformed Church, Doon, IADutton United Reformed Church, Caledonia, MIEscondido United Reformed Church, Escondido, CAFaith United Reformed Church, West Olive, MIFirst United Reformed Church, Chino, CAGrace United Reformed Church, Alto, MIHudson Valley United Reformed Church, New Hampton, NYImmanuel’s Reformed Church, Salem, ORImmanuel United Reformed Church, Abbotsford, BCMessiah’s Reformed Fellowship, Brooklyn, NYNew Haven United Reformed Church, New Haven, VTOak Glen United Reformed Church, Lansing, ILOrthodox Reformed Church, New Westminster, BCPreakness Valley United Reformed Church, Wayne, NJPompton Plains Reformed Bible Church, Pompton Plains, NJProvidence United Reformed Church, Strathroy, ONRedeemer United Reformed Church, Orange City, IARock Valley United Reformed Church, Rock Valley, IASioux Center United Reformed Church, Sioux Center, IATrinity Reformed Church, Lethbridge, Alberta, CanadaTrinity United Reformed Church, Caledonia, MITrinity United Reformed Church, Visalia, CAWest Sayville Reformed Bible Church, West Sayville, NYZion Reformed Church (RCUS), Menno, SDZion United Reformed Church, Ripon, CAOtherOther:*Please provide the full name of your churchDenomination*Please provide the denominational or federation affiliationChurch Address* City State / Province / Region Pastor/Elder from your church*We may wish to make your church aware of your desire to participate on this trip. First Last Is this person your pastor or elder?*PastorElderPastor/Elder Phone NumberPastor/Elder Email Address Are you having any of the symptoms listed below?*Select all that apply Hay fever, wheezing or asthma Eczema or frequent skin rashes Convulsions or seizures Heart trouble Diabetes Frequent colds, sore throat or earaches (4 or more annually) Trouble with passing urine or bowel movements Shortness of breath Speech problems Dental problems High sensitivity to poison ivy None Other: If you selected "Other," please describe:Previous operations or injuries:Medications needed or usedTypeFrequencyDosageReason AllergiesPlease list all allergies, one per line (medications, foods, environment) Click the plus sign on the right to add another row Have you received a tetanus vaccination in the past 5 years?*YesNoDate of last Tetanus shot* Date Format: MM slash DD slash YYYY Tetanus Vaccination Waiver*If necessary, I consent to receiving a tetanus vaccinationI do not want to receive a tetanus vaccinationTetanus Vaccination Waiver Signature*It is my stated decision to not have or allow a Tetanus vaccination administered to myself for any reason. I understand that by refusing to allow this procedure/treatment, I accept all responsibility for any medical conditions and/or complications that may result from this lack of treatment. I understand by signing this agreement, I release Reformed Mission Services, Inc., a New Jersey Not-for Profit Corporation, its employees, administrators, officers, directors, volunteers and agents and member churches, their pastors, officers, elders and deacons, volunteers and agents (collectively “RMS”) and the medical establishment where treatment is being sought from of and from any liability for any any and claims, including claims of RMS’s negligence, resulting in any physical or psychological injury (including paralysis and death), illness, damages, property damages, loss of use or economic or emotional loss. I also agree not to sue Reformed Mission Services, its Member Churches, or its designated Sponsors/Leaders for any liability for any claims of damages or injury to myself and my property. I have read this release and agreement not to sue. I hereby understand this agreement and bound by its provisions. Please sign your name with the mouse or finger on a touchscreenTetanus Vaccination Waiver Signature*As the parent or legal guardian of the above listed student, it is my stated decision to not have or allow a Tetanus vaccination administered to my child for any reason. I understand that by refusing to allow this procedure/treatment, I accept all responsibility for any medical conditions and/or complications that may result from this lack of treatment. I understand by signing this agreement, I release Reformed Mission Services, Inc., a New Jersey Not-for Profit Corporation, its employees, administrators, officers, directors, volunteers and agents and member churches, their pastors, officers, elders and deacons, volunteers and agents (collectively “RMS”) and the medical establishment where treatment is being sought from of and from any liability for any any and claims, including claims of RMS’s negligence, resulting in any physical or psychological injury (including paralysis and death), illness, damages, property damages, loss of use or economic or emotional loss. I also agree not to sue Reformed Mission Services, its Member Churches, or its designated Sponsors/Leaders for any liability for any claims of damages or injury to my child and my child’s property. I have read this release and agreement not to sue. I hereby understand this agreement and bound by its provisions. Please have your parent/guardian sign their name with the mouse or finger on a touchscreen Other ImmunizationsNameDate Name of Health Insurance Company*Enter N/A if you do not have anyHealth Insurance Policy Number*Enter N/A if you do not have anyGroup Number for Medical Insurance*Put N/A if you do not have a group number Release of Liability*In consideration for being allowed to participate in this Activity, on behalf of myself and my next of kin, heirs and representatives, I release from all liability and promise not to sue Reformed Mission Services, Inc., a New Jersey Not-for Profit Corporation, its employees, administrators, officers, directors, volunteers and agents and member churches, their pastors, officers, elders and deacons, volunteers and agents (collectively “RMS”) from any and all claims, including claims of RMS’s negligence, resulting in any physical or psychological injury (including paralysis and death), illness, damages, property damages, loss of use or economic or emotional loss I may suffer because of my participation in this Activity, including travel to, from and during the Activity. I am voluntarily participating in this Activity. I am aware of the risks associated with traveling to/from and participating in this Activity, which include but are not limited to physical or psychological injury, pain, suffering, illness, disfigurement, temporary or permanent disability (including paralysis), property damage, loss of use, economic or emotional loss, and/or death. I understand that these injuries or outcomes may arise from my own or other’s actions, inaction, or negligence; conditions related to travel; or the condition of the Activity location(s). Nonetheless, I assume all related risks, both known or unknown to me, of my participation in this Activity, including travel to, from and during the Activity. I agree to hold RMS harmless from any and all claims, including attorney’s fees or damage to my personal property, that may occur as a result of my participation in this Activity, including travel to, from and during the Activity. If RMS incurs any of these types of expenses, I agree to reimburse RMS. If I need medical treatment, I agree to be financially responsible for any expenses or costs incurred as a result of such treatment. I am aware and understand that I should carry my own health insurance. I agree Legal Adult Acknowledgement*I am 18 years or older. I understand the legal consequences of signing this document, including (a) releasing RMS from all liability, (b) promising not to sue RMS, (c) and assuming all risks of participating in this Activity, including travel to, from and during the Activity. I understand that this document is written to be as broad and inclusive as legally permitted by the laws of any and all states which may have or which may be claimed to have jurisdiction over the Activity. I agree that if any portion is held invalid or unenforceable, I will continue to be bound by the remaining terms. I have read this document, and I am signing it freely. No other representations concerning the legal effect of this document have been made to me. I agree. Dress Code*The RMS Board of Directors expect that all participants of this RMS sponsored trip will work together to honor the dress code. Ultimately, the responsibility of upholding this policy is left to the discretion of your Leaders and the RMS Board Representative on this trip. Because modest dress is often subjective to individual convictions and freedoms we have in Christ, please keep in mind the Biblical principles stated in 1 Corinthians 8:9 and Philippians 2:4 which encourage God’s people to avoid being a stumbling block by considering what is best for others. Therefore, please adhere to the following specifics of the dress code: ● SHIRTS: Shirts must be loose fitting, with sleeves (no tank tops), covers personal areas (midriff, cleavage, undergarments). Shirts must not contain writing or images that are unsuitable for a Christian. ● PANTS, SHORTS and SKIRTS: Pants, Shorts and Skirts must be mid-thigh in length or longer and loose fitting (no spandex or yoga pants). Please do not wear anything with writing on the seat. ● SWIMWEAR: Modest swimwear is mandatory. For women, a one-piece or tankini is permitted provided that all personal areas are well covered (midriff, cleavage). For men, no brief-style speedos. Please wear the type of bathing suit that allows you the most modesty. ● SHOES: Enclosed footwear (work boots, tennis shoes) is required on all job sites. Other footwear (flip-flops, sandals) may be worn at other times during the event. WORKSITE CONDITIONS: Remember that worksites can result in making one’s clothing dirty, so bring clothing you don’t mind getting ruined with the possibility of having to discard them after the end of your trip. CULTURAL REQUIREMENTS: additional dress code requirements may be required based on the particular culture of your trip location. Any specific additions or changes to this dress code will be addressed through correspondence prior to the trip. PARTICIPANT: I understand the dress code and will abide by it. General Rules and Guidelines*- No entering the rooms of persons of the opposite gender. - No possession or use of alcohol or tobacco at any time (see I Corinthians 8:9). - No possession of illegal drugs at any time. No weapons, explosive devices, etc. - Participants will respect all property and may be held responsible for property damages incurred. - Attendance at all functions is mandatory. Attendants are not permitted to leave the group for personal reasons except urgencies. - Electronic equipment such as cell phones and laptop computers are permitted for adults provided they are used primarily for the project. - Please refrain from using electronic devices during the event to promote Christian fellowship and unity. - Participants will adhere to the dress code at all times. PARTICIPANT: I promise to fully participate in all aspects of my RMS project. I have read the rules and promise to abide by them. Minor Participant Authorization*I am the parent or legal guardian of the Participant. I understand the legal consequences of signing this document, including (a) releasing RMS from all liability on my and the Participant’s behalf, (b) promising not to sue on my and the Participant’s behalf, (c) and assuming all risks of the Participant’s participation in this Activity, including travel to, from and during the Activity. I allow Participant to participate in this Activity. I understand that I am responsible for the obligations and acts of Participant as described in this document. I agree to be bound by the terms of this document. I have read the waiver on the previous page, and I am signing it freely. No other representations concerning the legal effect of this document have been made to me. I, the parent/guardian of this minor, agree. Restrictions & Other Conditions*RMS is committed to caring for the needs of each person who attends our trips. We understand that you may desire to communicate personal or private information that is helpful/necessary to ensure your well-being on this trip. For the sake of maintaining confidentiality, we invite you to check the box below so the RMS Director knows to connect with you prior to the trip. Our Director will work with you to determine the best course of action. Therefore, are there any special needs that you believe important to share with RMS in order to help assure your well-being on the trip? If so, the RMS Director will contact you prior to your trip.YesNoParticipant Signature*I have answered all the above questions to the best of my knowledge Please sign your name with your mouse or finger on a touchscreenParent/Guardian Signature*I approve my son/daughter’s participation on this RMS project. I have filled in the "Restrictions and Other Conditions" section to the best of my knowledge. I have read and discussed the rules with my son/daughter and agree to abide by all decisions made by the leadership of RMS. I understand that violation of the rules may result in my child being sent home at personal expense.Please sign your name with your mouse or finger on a touchscreenGeneral CommentsIs there anything else that you would like to share with us? Would you like to pay the administration fee online?*If no, please submit your payment to: RMS 2111 Pine Ridge Drive Suite G Jenison, MI 49428YesNoTrip Registration Fee* Price: $450.00 Trip Registration Fee* Price: $1,025.00 Trip Registration Fee* Price: $500.00 Trip Registration Fee* Price: $1,200.00 By God’s grace, we have not had any child abuse incidents in RMS history. However, we are convicted that we need to do as much as we can to prevent it. Therefore, beginning March 1, 2017, RMS is implementing the use of training and background checks for all adults 18 years and older at the time of trip participation. Once you have completed this form, you will be referred Protect My Ministry which is the company we are using to run the background checks for us. Once you submit this form, you will be redirected to the form for the background check. You will receive an email from us as a confirmation and it will include the link to the background check form if you wish to fill it out later. It should take approximately 5 minutes.
