Rise Mission Trip 2025 (Servio Deo)

Student Information

Individuals who have attended 7th -12th grade in the 2024/2025 school year. If you have any concerns regarding this please contact Frankie Tripodi.

Name

Gender

Female Male

T-shirt Size (adult size)

Small Medium Large XL XXL XXXL

Student phone number (will likely be utilized on the Mission Trip)

Grade in Fall 2025

2025 Graduate 12th 11th 10th 9th 8th

Birthdate

Parent/Legal Guardian Information

Parent/ Legal Guardian Name

Parent/Legal Guardian phone number

Please enter the best email in the household to receive Mission Trip Info. To enter more than one, simply separate the addresses with a comma, for example - lifeteen@email.com, lifeteen@email.com

This address will receive a confirmation email

Enter all phone numbers you would like to receive text message reminders. For more than one, simply use a comma: 615.555.5555, 615.333.3333

Parent Opportunities

Myself or my spouse can commit to chaperone and drive on this Mission Trip. Myself or my spouse might be able to help if you are REALLY struggling to find enough chaperones. I would be willing to help volunteer raise money for the Mission Trip. I would be willing to help prep beforehand for this Mission Trip. No adult in our family can chaperone but I am willing to pray for those on the trip and all the people they are serving. I am a nurse, doctor, first-responder and I can help volunteer . I have experience with construction and or other maintenance skills .

Emergency Contact

Emergency Contact Name (an adult that is not listed above)

Emergency Contact Phone Number

Relationship to Student

Health Information

Please check all that apply for your student.

Medicinal Allergies Environmental Allergies Food Allergies Dietary Accommodations Meds they need help taking on the trip Medical Conditions Other Medical, Educational, or Psycological info that we would need to be aware of while on this trip Other info None of these apply

List any medicinal, environmental, and food allergies as well as any dietary accommodations your student will need.

List of Meds that need to be taken. Please indicate which meds they need help taking & what time they should be taken.

List of Medical or Psychological Conditions we need to be aware of to help your student. Please share how we can practically help your student while on this trip.

Anything else you'd like us to know about your student who will be attending Mission Trip with us?

Release and Waivers

Liability Waiver and Medical Release:
I give permission for my child to participate in this mission trip that requires transportation to a location away from the parish, school and Diocese. This activity will take place under the guidance and direction of parish employees and/or volunteers from St. Matthew Catholic Church. As parent and/or legal guardian, not St. Matthew Catholic Church, Diocese of Nashville, Ridgecrest Conference Center or those acting as chaperones, retain full legal, physical, and financial responsibility for my child’s personal actions. I agree on behalf of myself, my heirs, assigns, executors, and personal representatives, to hold harmless and defend St. Matthew Catholic Church, Diocese of Nashville, its officers, directors, agents, employees, volunteers, or representatives associated with this mission trip from any and all liability claims, loss or damage arising from or in connection with my child’s participation in this mission trip. In the event of an emergency, I give permission for any medical treatment deemed necessary by the Saint Matthew staff. I also give permission to transport my child to any reasonably accessible hospital or physician’s office. I remain financially responsible for my child’s medical treatment.

By typing my name here, I signify that I am the parent or legal guardian of the student and I agree to the release/ medical waiver detailed above.

Parent/Legal Guardian Name serving as digital signature

Today's Date

Media Waiver Release:

I give consent for my child to be in photos and videos used to promote the Diocese of Nashville, Saint Matthew Catholic Church, and Catholic faith leaders. I understand that the images may be used in print publications, online publications, presentations, websites, and social media. I also understand that no royalty, fee or other compensation shall become payable to me because of such use.

Media Release Options

I agree to the Media Release I do not give permission for my student's image to be used in the above mentioned manner.

By typing my name here, I signify that I am the parent or legal gaurdian of the participant and I agree to the media release detailed above.

Parent/Legal Guardian Name serving as digital signature

Today's Date

Insurance Info

Name of Primary Card Holder for Insurance

Picture of Front of Insurance Card

Upload (8MB)

Picture of Back of Insurance Card

Upload (8MB)

Payment

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

Rise Mission Trip 2025 (Servio Deo)

Description

Please Fix the Following