Name:*

Email:*

Phone:*

Fax:

Website Address:

Street Address 1:*

Street Address 2 (Optional):

City:*

State:*

Zip:*

First Name:*

Last Name:*

Address:*

City:*

State:*

Zip:*

H Phone:*

W Phone:*

Choose Date of Attendance:* Mar 22-26April 4-9April 11-16June 20-25 - FULLJune 27-July 2 - FULLJuly 4-9July 11-16July 18-23July 25-30Aug 1-6Aug 8-13

Choose Alternate Date of Attendance:* Mar 22-26April 4-9April 11-16July 4-9July 11-16July 18-23July 25-30Aug 1-6Aug 8-13

Gender Breakdown (enter a number for each)

Male:*

Female:*

Ages of Group (enter a number for each)

Under 12:*

12-15:*

16-18:*

Adults:*

Mode of Travel (number and type of vehicles):*

Please list physical skills of adults/students in your group (plumber, carpenter, electrician, drywall, etc.):*

Has your group taken a mission trip in the past five years?*

YesNo

If yes, where?

Would you be willing to make a pre-trip visit before your group comes out?*

YesNo

How did you hear about SLAM TRIPS?*

WebsiteMailFriend or ColleagueOther

Additional Information