Complete and copy the following form and email it to: smi.imabeliever@yahoo.com or FAX it to (480) 899-5008, or mail it to the address at the top of this form.

Emergency Information:

Name ____________________ DOB ___________________ Age ____ Gender ______

Address ___________________________  City _______________________ 

State  _____   Zip _________

Emergency/Guardian Contact:  ______________________________

Relationship ___________________

Contact numbers:  Work:  ___________________  Cell:  _________________ 

 Home:  ________________

Family Physician:  _______________________________

Phone Number:  _________________________

List any known allergies or health problems that SMI should be aware of:  ____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

I consent to the terms of the liability waiver and will not hold Spurdle Ministries International nor any of the other afore agreed churches and individuals responsible according to the terms of the agreement.  I am/we are the legal parent(s)/guardian(s) of _____________________________ and I/we consent to his/her short-term missionary trip by my/our signature below.

__________________________________   ________________________________

Signed                                                 Signed

If you desire travel insurance, we recommend you visit the website of Double Honor Insurance Services, LLC. – https://doublehonor.net:450/index.htm – or call them at 888-288-9953.  They have rates as low as $2.20 per day over 19 years of age and as low as $1.10 per day for under 19 years.