"Transforming Lives for Christ Through Middle School Mission & Ministry"    

Which Church are you from?

Select Your Church Aldersgate UMC - Alexandria Aldersgate UMC - Charlottesville Andrew Chapel UMC Annandale UMC Bedington UMC Bellamy UMC Bethany UMC Blacksburg UMC Brandermill Church Burke UMC Cameron UMC Centreville UMC Chestnut Memorial UMC Christ Episcopal Church Christ UMC - Fairfax Station Christ UMC - Newport News Christ UMC - Staunton, VA Fairfax UMC Fairlington UMC First Presbyterian of Va. Beach Floris UMC Gainesville UMC Grace UMC Great Bridge UMC Great Falls UMC Kirkwood Presbyterian Manassas St. Thomas UMC Marquis Memorial UMC Mint Spring UMC Mt. Olivet UMC New Town UMC Relief UMC Reveille UMC Sandbridge Community Chapel UMC Shady Grove UMC Silverbrook UMC Springfield UMC Spring Branch Community Church St. Marks UMC - Daleville, VA St. Marks UMC - Hampton St. Matthews UMC - Annandale St. Matthews UMC - Goochland St. Paul UMC - Staunton St. Stephens UMC Sydenstricker UMC Virginia Beach UMC Williamsburg UMC Other

Select the week you are submitting your team roster for.  If you are bringing teams multiple weeks you will need to submit a separate roster for each week.

Select Your Week June 22-28 June 29-July 5 July 6-12 July 13-19 July 20-26 July 27-August 2 - VA July 27-August 2 - WV August 3-9- VA August 3-9 - WV

1. Name of Participant:

Student  Adult

Male    Female

Select current grade or Adult: Select Current Grade or Adult 6th Grade 7th Grade 8th Grade 9th Grade Adult

Email Address (adult participants only):

Street Address:

City: Select a City Aldersgate UMC - Alexandria Aldersgate UMC - Charlottesville Alexandria Annandale Arlington Blacksburg Bristow Burke Centreville Chantilly Charlottesville Chesapeake Dale City Daleville Fairfax Fairfax Station Falls Church Fincastle Gainesville Gloucester Gloucester Point Goochland Great Falls Hampton Hayes Haymarket Herndon Lorton Manassas Manassas Park Martinsburg McLean Midlothian Mint Spring Newport News Norfolk Oakton Reston Richmond Springfield Staunton Stephens City Stuarts Draft Toano Vienna Troutville Virginia Beach Warrenton Williamsburg Winchester Woodbridge Yorktown Other   Other City:

State:  VA WV MD NC

Zip:

Phone with area code:

Medical:
Medical Conditions/Special Needs for this person (if none, leave space blank):


Special Skills:
List Special Construction Skills (please specify skills):

Other Information:
Other information on this person that we need to be aware of
(please list any persons with special dietary needs): 

Please complete this next section for each one of your adult leaders:

Has this adult had both required background checks performed on him/her:

1. Criminal History Background Check.
2. Sex Offender Background Check.

(These background checks may be completed through an agency the individual church deems reliable and trustworthy)

Please Select No Yes In Process

Mission Trip Experience: 
Participated with JP in the past? 
Yes  No

Participated with other mission organizations?
Yes  No

Please review your information carefully before submitting this form - thanks!