REGISTRATION FOR 2012 POWER MEN'S TRIP:

First Name:
Last Name:
Name you go by:
Address:
City:
State:	Select a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinios Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip:
Home Phone:	- -
Cell Phone:	- -
Work Phone:	- -
Email:
Birthdate:	Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912
Wife's Name:
Anniversary Date:	Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942
Church You Attend:	Select Bellevue Foursquare Church, Bellevue, Wa. Bridges Christian Fellowship, Riverside, CA Calvary Bible Church, Bellevue, ID Calvary Chapel Moreno Valley, Moreno Valley,Ca Calvary Chapel Of Ridgecrest, Ridgecrest, Ca. Calvary of the Cross, Riverside, Ca. Central Community, Riverside, Ca. Christian Assembly, Pasadena, Ca. Compass Church, Colleyville Tx. Crossings Community Church, Grand Terrace, Ca. Crossroads Church, Corona,Ca. Crossroads Community Church, Ridgecrest, CA Crossroads Nazarene, Mesa, Ar. Desert Christian Center, Ridgecrest, Ca. Desert Hills Community Church, Gooding, ID East Hills, Riverside Faith Mission, Del Rio, TX Faithlife Church, Corona, Ca. Fellowship of the Pass, Beaumont, Ca. First Baptist Church of Rome, Rome Ga. First Presbyterian Church of Rome, Rome, Ga. Foundation Christian Ministry, Cedar Creek, Tx Glad Tidings, Cedar Creek, Tx. Gooding First Christian Church, Gooding, Id. Gooding First Christian Church, Gooding, ID Grace Community, Riverside, CA Harvest Christian Fellowship, Riverside, CA Higher Ground Calvary Chapel, Moreno Valley, Ca. Hope Community, Riverside, Ca. House of Prayer, Montecello, NY Iglesia Emmanuel, Acuna, MX Immanuel Baptist Church, Ridgecrest, Ca. Inland Valley, Temecula, CA Inland Vineyard Christian Fellowship, Corona, CA. Magnolia Presbyterian, Riverside, CA Mariners Church, Huntington Beach, Ca. Maurice 1st Reformed, Maurice, Ia. Mount Union C & MA, Mount Union, PA New Day Christian Fellowship, Riverside One Voice Church, Los Angeles, Ca. Pathway Christian Church, Riverside, Ca. Ridgecrest United Methodist, Ridgecrest, Ca. Riverside Baptist Church, Riverside, Ca. Rock Harbor, Costa Mesa, Ca. Sandals Church, Riverside, Ca. Sherwood Foursquare Church, Sherwood, OR The Grove Community Church, Riverside, CA United Baptist Church, Laredo, Tx. Victory Baptist Church, Ridgecrest, Ca.
If other please specify:
Church Address:
Occupation:
Shirt Size:	S M L XL XXL XXXL
Skills:
General Construction	Select Expert Good Fair Little None	Addtional Info:
Electrical	Select Expert Good Fair Little None	Addtional Info:
Drywall	Select Expert Good Fair Little None	Addtional Info:
Plumbing	Select Expert Good Fair Little None	Addtional Info:
Carpentry	Select Expert Good Fair Little None	Addtional Info:
Cement	Select Expert Good Fair Little None	Addtional Info:
Roofing	Select Expert Good Fair Little None	Addtional Info:
Heating and AC	Select Expert Good Fair Little None	Addtional Info:
Welding	Select Expert Good Fair Little None	Addtional Info:
Handyman	Select Expert Good Fair Little None	Addtional Info:
Automotive	Select Expert Good Fair Little None	Addtional Info:
Electronic	Select Expert Good Fair Little None	Addtional Info:
Spanish	Select Expert Good Fair Little None	Addtional Info:
Sports	Select Expert Good Fair Little None	Addtional Info:
Forklift Driver	Select Expert Good Fair Little None	Addtional Info:
Strong Lifter	Select Expert Good Fair Little None	Addtional Info:
Organizer	Select Expert Good Fair Little None	Addtional Info:
Photography	Select Expert Good Fair Little None	Addtional Info:
Videography	Select Expert Good Fair Little None	Addtional Info:
Computers	Select Expert Good Fair Little None	Addtional Info:
Web	Select Expert Good Fair Little None	Addtional Info:
Medical Knowledge	Select Expert Good Fair Little None	Addtional Info:
GPS Familiarity	Select Expert Good Fair Little None	Addtional Info:
Other Areas of Interest:
Other Areas of Expertise:
Are you a pastor?	Yes     No
Would you be willing to be in a late-night prayer group?	Multiple Times     Just Once     No Thanks
Would you be willing to lead a prayer group?	Yes     No
Are you comfortable praying out loud with the group?	Yes     No
Would you be willing to give your testimony?	Yes     No
Would you be willing to lead a devotion?	Yes     No
Are you interested in being a van driver?	Yes     No     Either
Driver License #:
Expiration:
Would you be willing / are you qualified to pull a trailer?	Yes     No
If there is a need, would you like to:
Visit a prison?	Yes     No     Either
Sing on the worship team?	Yes     No     Either
Play guitar or keyboard with the worship team?	Yes     No     Either
Be on the puppet team? (Pre-trip practices mandatory.)	Yes     No     Either
Be on a food preparation crew?	Multiple Times     Just Once     No Thanks
Have you ever been on a missions trip besides a POWER trip?	Yes     No
If so, where?
How many trips?
Do you have any physical limitations?	Yes     No	Addtional Info:
Do you have any medical restrictions?	Yes     No	Addtional Info:
Do you have any special nutritional needs?	Yes     No	Addtional Info:
Will you work on Sunday?	Yes, after church     No
Group 1	January 16–23, 2012
Group 2	January 25–February 1, 2012
Do you have a passport?	Yes     No	Passport #
Would you like POWER to secure your airline tickets?	Yes No
	By submitting this registration form, I agree to pay a non-refundable $325 deposit towards my trip costs.
How did you hear about POWER?