Application for Spring Break Service Project
Cary Christian Center, Cary, Mississippi
March 11-18, 2006
Please print. Return to Ed Laarman at Geneva Campus Ministry, Room 104, Wesley Center, 120 N. Dubuque St., Iowa City, IA 52245. Questions? Call 319/341-0007 (office) or 319/594-2621 (cell), or email geneva@uiowa.edu. Include $10 in cash or a check to “Geneva Campus Ministry” with your application.
Name_____________________________ Email________________________________
Cell Phone_________________________ Home Phone__________________________
Campus Address__________________________________________________________
Parent(s) and/or Other Contact(s)in Case of Emergency:
Name_________________________Phone____________________Relationship____
Name_________________________Phone_____________________Relationship____
Name_________________________Phone_____________________Relationship____
Insurance Information
Do you have medical insurance?________ Name of company_____________________
Policy No.___________ Group No.__________ Name of Policyholder______________
Health Information
What is the general state of your health?______________________________________
Do you have any physical conditions, medications, allergies, or psychological conditions we should be aware of ? _________________________________________________ ________________________________________________________________________
________________________________________________________________________
Are there any physical limitations on the kind of work you can do(e.g. no heavy lifting, no climbing on ladders)?___________________________________________________
Skill Levels
In each category below, note your skill level: professional, skilled, semi-skilled, some experience, no experience. Add comments if they would be helpful.
Home Repair____________________________________________________________
Painting_______________________________________________________________
Child Care_____________________________________________________________
Clothing (sorting, arranging)______________________________________________
Clerical/data entry_______________________________________________________
Other__________________________________________________________________
Finances
Total cost of the trip is $265. Includes travel by van, dormitory housing, meals at Cary Christian Center (we will prepare our own), and $20 towards work supplies. Not included is the cost of meals on the road, meals out, souvenirs, etc. Payment schedule:
$ 10 Deposit with the application (not refundable if you are accepted for the trip)
$100 Due Feb. 15 to hold your place (all refundable if you must drop out because of
unavoidable circumstances or if a replacement can be found; if neither
applies, only $50 is refundable because of fixed costs for the trip)
$155 Due March 9 (not refundable except in an emergency situation)
Please pay in cash or make checks out to “Geneva Campus Ministry” and note “Cary Trip” on the memo line. Receipts on request. A limited amount of funds are available for partial scholarships. If you would like to apply, please fill out the spaces below:
_________ Scholarship amount requested. Reason for financial need________________
Requirements and Rules
A meaningful and enjoyable trip requires that everyone is willing to:
- Work hard at whatever tasks we are assigned
- Be courteous to and cooperate with other members of the group
- Show respect for all persons we meet and for the culture and faith they embrace
- Learn from the people we meet and the experiences we have
- Follow directions from the group leaders and the staff of Cary Christian Center
- Participate in the spiritual activities of the group (whatever one’s own beliefs)
Some of the rules for the trip include:
- No use or transport of alcohol or illegal drugs, or intimate sexual activity
- Stay with the group unless you have permission to leave, and make sure someone
knows where you are at all time
- Curfew is 12:30 a.m. unless otherwise notes (we will need our rest!)
Other comments or questions?
I hereby apply to participate in the trip and agree to abide by the requirements and rules above, and to general standards of good conduct.
Signed________________________________________Date_____________________
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For further information contact: