2025 Moving Mountains Mission Trip

Moving Mountains Mission Trip
Click here for more information about this trip at the Moving Mountains Mission Trip website and click here for the informational packet.

Pre-Registration

Read First - Before you start the online registration, create a digital copy (front and back) of the medical insurance card that will be used to cover the participant on the trip. There is a step during the process that requires an upload of a copy of the insurance card. You will also need the primary care provider’s information.

After completing the online registration, there are additional requirements* that parents, guardians, adult chaperones and teen participants will complete at their local parishes or with The Diocese. Please check with your parish leader or trip coordinator for additional information on those requirements.

*Additional Requirements
Parents of Teens
- Complete the sponsoring parish’s liability/consent/mission forms
- The two Grace House on the Mountain release forms

Adults and Teens 18 years of age and over
- Complete The Episcopal Diocese of Virginia Misconduct Prevention (Safe Church)

Registration

There are 5 sections to the online registration. Respond with the required information. Please provide all required information.

There is no way to save information if you stop in the middle of registration (at the time). The process usually takes about 8-11 minutes to complete, if you have your information available.

Sections
Section 1 - Parent, Guardian and Participant Information
Section 2 - Medical Contact (Prioritized list of phone contact numbers)
Section 3 - Medical Insurance (Upload insurance card)
Section 4 - Acknowledgements Mission Norms/Liability Release
Section 5 - St Anne’s Participants Payment Portal

Section 1 - Parent, Guardian and Participant Information

This section collects the participant’s name and contact information and identifies parent or guardian for teens participants who will be younger than 18 on June 14, 2025.

Participant Name

Participant Date of Birth

Participant Mobile Phone

Participant Email

Participant Address

How many Appalachian Mission Trips (including this one) has the participant attended?

1 2 3 4 5+

Participant T-shirt Size

Youth-Small Youth-Medium Youth-Large Adult-Small Adult-Medium Adult-Large Adult-XL Adult-XXL Adult-XXXL

Parent/Guardian Name (Please re-enter your name if 18 or older)

Parent/Guardian Phone 1 (daytime)

Parent/Guardian Phone 2 (nighttime)

Parent/Guardian Email (Please re-enter your email if 18 or older)

This address will receive a confirmation email

Do you want a carbon copy of email communications to also go to teen participant listed above?

Yes No

Section 2 - Medical Contact (Prioritized phone contact numbers)

This section collects for contact information for adults with the authority to discuss the participant’s medical information. Parent/Guardians are preferred, but all are welcome. Contact person may participate in medical consultations with chaperones or medical professionals. If needed, the person may also be contacted for mission norms and behavior discussions.

Parent/Guardian #1

Participant's relationship with #1

Daytime Phone Number for #1

Nighttime Phone Number for #1

Parent/Guardian #2

Participant's relationship with #2

Daytime Phone Number for #2

Nighttime Phone Number for #2

Parent/Guardian #3

Participant's relationship with #3

Daytime Phone Number for #3

Nighttime Phone Number for #3

Section 3 - Medical Information

This section collects the insurance information for the mission trip participant. A digital copy of the insurance card is needed to complete the registration.

Insurance Information

Insurance Company

Policy Holder’s Name

Policy Number

Please upload a copy of the insurance card (front and back) to be used to cover participant.

Upload (8MB)

Primary Care Provider

PCP Hospital/Office Name

PCP Doctor Name

PCP Address

PCP Office Phone

Participant's Medical Summary

This section is to collect information to get a general summary of the participants medical status, detail current medical conditions, list current and future medications and other factors that may limit or constrain participation.

Responses starting with words like excellent, good, fair, condition is…, assistance is needed when… are preferred.

Use N/A to indicate areas of concern that are not applicable to the medical state of the participant.

General Health Status

Medications currently taking

Reasons for medication

Allergies (food, drug, etc.)

Physical limitations

Other pertinent medical information

Section 4 - Liability Release Acknowledgement

Note: You are encouraged to download and keep copies of these documents for your own records.

St. Anne’s Photography Release read here.

Do you understand and agree with the terms of the photography release?

Yes

St Anne’s Informed Consent read here.

Do you understand and agree with the terms of the informed consent?

Yes

Grace House Liability Waiver
Open the Grace House Liability Waiver.

There are two requirements:
1. A wet signature is required. Download, print, sign and turn-in the completed waiver document to your Parish Coordinator.
2. Acknowledgment is required below.

I have downloaded the Grace House Liability Waiver and will follow instructions above.

I Agree

Grace House Community Expectations
Open the Grace House Community Expectations document.

There are two requirements:
1. A wet signature is required. Download, print, sign and turn-in the completed expectations document to your Parish Coordinator.
2. Acknowledgment is required below.

I have downloaded the Grace House Community Expectations and will follow instructions above.

I Agree

Section 5 - St Anne’s Participant Payment Portal

NOTE: The following payment capability on this form is available to ST. ANNE'S PARISHIONERS ONLY. If you are from another church, please send your payment directly to your parish Mission Trip coordinator directly, by the means they have prescribed (check, credit card, online payment, etc.).

Payment $350 (Pay now or by May 15.)

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

2025 Moving Mountains Mission Trip

Description

Please Fix the Following