Application for Clarkston - Center for Great Commission Studies

Traveler Information

Full name must be an EXACT match of your passport or drivers license. There is a minimum $200.00 fee for name changes. If you are applying for an international mission trip, a passport is required.

Name (As shown on Driver's License, Real ID, or Passport)*

Again, this must be an EXACT match of your passport or driver's license.

First Middle Last

State of Residence (As shown on Driver's License, Real ID, or Passport)*

Student ID*

Are you a Distance-Learning (online) Student?*

Online

Campus

This trip requires that you travel with the team from Wake Forest. You are responsible for travel arrangements to Wake Forest.*

Agree

Disagree

Name of House (If in the College):*

School Affiliation for Course Credit*

What degree are you pursuing?*

What is your Major/Concentration?*

Gender*

Male

Female

Phone Number*

Student Email*

Preferred Email*

This email is the email you check with regularity and will answer swiftly.

Date of Birth*

Marital Status*

Single

Married

Spouse Name (If Applicable)

Are You a US Citizen?*

Yes

No

If you are not a US Citizen, please indicate where your citizenship resides:*

Where is this trip going?*

The Clarkston trip is designated as Stateside. Please choose stateside on this question.

International

Stateside

Passport Country*

Passport Number*

Have you ever been on a mission trip? Describe your experience.*

Why do you desire to go on this trip?*

Emergency Contact Information

This is required for all trip communication and in case of Emergency. Your emergency contact should not be travelling (on this mission trip) during the length of the mission trip.

Emergency Contact Name*

First Last

Relationship*

Gender*

Male

Female

Emergency Contact Phone Number*

Emergency Contact Email

Medical Conditions

Please list any medical conditions you may have that we need to be aware of.

Beneficiary Name*

A person designated as the recipient of funds or other property under a will, trust, insurance policy, etc. This is required for travel insurance.

First Last

Beneficiary Phone*

Course Agreement

Southeastern Baptist Theological Seminary is an institution of learning. Therefore, all mission trips are attached to a class. By completing this application, you are agreeing to be a part of the class for this trip. Should you choose not to complete the work for this course, you will receive a failing grade which will negatively affect your GPA.

By clicking 'Agree' below, you are indicating that you agree to be apart of the class for this trip. Should you choose to disagree your eligibility for this mission trip will be disqualified.*

Agree

Disagree

Indemnity Agreement and Release*

In consideration of my participation with the mission trip to Clarkston, with The College at Southeastern during Fall Break 2023, the dates of September 30th through October 6th, I, a participant with The College at Southeastern academic project do hereby release, discharge and covenant to hold harmless The College at Southeastern and Southeastern Baptist Theological Seminary, its officers, trustees, employees, agents, advisers, administration, heirs or assigns, (herein referred to SAID PARTIES) from any and all claims, demands, damages, costs, expenses, actions and causes of action, present and future, on account of injuries to my person or property, and even injuries resulting in death, arising out of or in connection with my participation in The College at Southeastern Mission Project.

I agree and understand that The College of Southeastern considers its travel programs to be an extension of its campus, so the same behavior and expectations are expected by all team members as they would be on the SEBTS campus. Therefore, I agree to abide by its normal rules and regulations applicable during the period of foreign travel and study. I further understand that students participating in the aforementioned mission project are expected to exercise good judgment in taking safety and health precautions, in planning their time, in maintaining good conduct and in continuing their educational pursuits and I agree to do so.

In further consideration of my being permitted to participate with the The College at Southeastern mission project, I, my spouse, my heirs and assigns hereby assume all and full responsibility for the risks, foreseen or unforeseen of personal injuries, death or property damage incurred while participating in the aforementioned activity. I further agree to indemnify SAID PARTIES for and hold them forever harmless from all claims, demands, damages, costs, expenses, actions and causes of action they or Southeastern Baptist Theological Seminary may incur as a result of my participation in the mission project sponsored by The College at Southeastern.

It is hereby further agreed: that no promise or agreement not herein expressed has been made; that this release is not executed in reliance upon any statement or representation made by SAID PARTIES, or any of them, or by any person employed by or representing them, or any of them; that said consideration is the sole and only consideration for this Indemnity Agreement and Release; and that the terms hereof are contractual and not mere recitals.

*This indemnity agreement and release shall be governed by the laws of the state of North Carolina.*

By checking this box, you are indicating that you have read and acknowledge the above Indemnity Agreement and Release Statement.

I understand that by typing my full name below, I agree to comply with the above Indemnity Agreement and Release statement. I further state that I sign the same as my own free act. Please type your full first, middle, and last name below.*

Today's Date*

Spouse: If applicable, please have your spouse type their full first, middle, and last name varifying their compliance with the above Indemnity Agreement and Release statement.

Today's Date

Phone

This field is for validation purposes and should be left unchanged.

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MT - Clarkston House Trip - Fall Break 2023

Traveler Information

Emergency Contact Information

Course Agreement