2024 Trip Registration Entry Form for Dave Coryell Participant Infomation First Name you go by* Last Name* First Name* As it appears on government ID Middle Name Required for airline tickets and those wishing to be drivers Address* City* State* AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY CN-AB CN-BC CN-MB CN-NB CAN-NL CN-NT CN-NS CN-NU CN-ON CN- PE CN-QC CN-SK CN-YT MX-BN MX-BS MX-CA MX-NL MX-SO MX-TM Country Zip Code* Cell Phone* ###-###-#### Home Phone ###-###-#### Work Phone ###-###-#### Email* Must be unique to Power. Not the same as another Power member. Personal Information Birthday* mm/dd/yyyy Wife's First Name Anniversary mm/dd/yyyy Church you attend* Access Church Alamo Ranch Community Church Alianza Cristiana Amazing Grace Fellowship Antioch April Sound Church Austin Christian Believers Church Bellevue Foursquare Church Bethel A/G Church Big Bear Community Church Bridges Christian Fellowship BT McAllen Buckhead Church Calhoun Methodist Calvary Chapel Buhl Calvary Bible Church Calvary Chapel Moreno Valley Calvary CRC Calvary Fellowship Canby Christian Cedarcrest Celebrate Church Central Christian Church CFTN Church for the Nations Church On The Hill Church On The Move Clairemont Emmanuel Baptist Compass Church Cross Life Community Church Crosspoint Church Crossroads Church Crossroads Community Church Desert Hills Community Church East Hills Community Church El Buen Samaritano Faith Bible Church Faith Evangelical Free First Baptist Church of Newport First Baptist Church of Rocksprings First Baptist Church of Rome First Presbyterian Church of Rome Gold Coast Christian Church Gooding Springs Calvary Chapel Gooding First Christian Church Grace Bible Grace Community Grape Creek Family Fellowship Harvest Christian Fellowship Icmf Church Immanuel Baptist Kingdom Strong International Laredo Church Of The Crossroads Life Church Magnolia Presbyterian Mariners Church Maurice 1st Reformed McEachern Memorial UMC Misson Church Moreno Valley Mountain Brook New Bethel New Day Christian Fellowship North Coast Live Palm Valley Church Parma Heights Baptist Pathway Christian Church PDX Simple Church Real Life Austin Relevant Church Rock Family Church Rock Harbor Saddleback Saddleback Irvine South Sandals Church Shepherd's Grove St. Mary The Fellowship at Two Rivers The Garden Church The Grove Community Church The Way Church Waldport Community Bible Church Woodstock City Yorba Linda Friends Church None other Occupation Hobbies, Gifts, Talents, Expertise, other Interests too many to list them Trip Related Information Group 1 January 10-17, 2024 Trip Group 2 January 18-24, 2024 Trip Group 3 March 6-13, 2024 Trip Shirt Size* ----- S M L XL XXL XXXL Are you willing to visit a prison? Are you willing to visit a prison? Yes No Either Do you play guitar or keyboard? Do you play guitar or keyboard? Yes No If yes, would you be willing to play with worship team if needed? If yes, would you be willing to play with worship team if needed? Yes No Are you a pastor? Are you a pastor? Yes No Are you willing to lead prayer? Are you willing to lead prayer? Yes No Are you willing to pray out-loud? Are you willing to pray out-loud? Yes No Do you have a passport?* Do you have a passport? Yes No Applied For A passport is a MUST Passport Expiration Date The expiration date must be at least 6 months after the end of our trip. Are you interested in being a van driver? Are you interested in being a van driver? Yes No Either Driver Information For those wishing to be drivers please complete the following section, All information is required: Driver License Number License Class Commercial Driver Commercial Driver Yes No License State AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY CA-AB CA-BC CA-MB CA-NB CA-NL CA-NT CA-NS CA-NU CA-ON CA- PE CA-QC CA-SK CA-YT MX-BN MX-BS MX-CA MX-NL MX-SO MX-TM License Expiration Date mm/dd/yyyy Are You Married Are You Married Yes No Medical issues Medical issues Yes No Are you aware of any condition that may affect your vision, hearing, perception, reflexes, flexibility, or judgment? Medication Medication Yes No Do you take any medications that warn against driving/operating equipment? If your answer is YES to any of the above questions please explain each occurrence Have you attended a Traffic Safety Course? Have you attended a Traffic Safety Course? Yes No Have you ever been convicted of a criminal offense? Have you ever been convicted of a criminal offense? Yes No If your answer is YES please provide the date and description of each conviction Check the vehicles you have driven in the past: Bus Heavy Truck Tractor Trailer Skills You Have General Construction None Little Fair Good Expert Electrical None Little Fair Good Expert Drywall None Little Fair Good Expert Plumbing None Little Fair Good Expert Carpentry None Little Fair Good Expert Roofing None Little Fair Good Expert Heating and AC None Little Fair Good Expert Painting None Little Fair Good Expert Handyman None Little Fair Good Expert Automotive None Little Fair Good Expert Electronic None Little Fair Good Expert Sports None Little Fair Good Expert Strong Lifter None Little Fair Good Expert Organizer None Little Fair Good Expert Photography None Little Fair Good Expert Videography None Little Fair Good Expert Computers None Little Fair Good Expert Web None Little Fair Good Expert Writing None Little Fair Good Expert Spanish None Little Fair Good Expert Medical Knowledge None Little Fair Good Expert Power Involvement If so, where? Reynosa, El Shadai Have you ever been on a missions trip besides a POWER trip? Have you ever been on a missions trip besides a POWER trip? Yes No How did you hear about POWER? bridges & power guys Medical Information Emergency contact person* Contact relationship* Contacts phone number(s)* ###-###-#### Medical insurance company* Date of last tetanus shot* List physical limitations if any: Strained Back, compressed disk List allergies if any: Mountain Cedar List medical disorders if any: Diabetic (type 2), High BP List special medication if any: List special nutritional needs if any: I have verified all my information* Please be sure all information is correct and up to date before proceeding.
