Fill this in by hand and mail it with your check.
Trip: Flambeau River Canoe Trip · Flambeau River, WI · 6/28/2027 – 7/7/2027
Mail to: Chadash Christian Ministries, PO Box 271, Medford, WI 54451. Include the non-refundable $250 application fee by check, payable to Chadash Christian Ministries.
Name
Age
Date of birth
Street address
City
State
ZIP
Phone
Cell phone (if different)
Parent/legal guardian names
Name of church you presently attend
Pastor
Pastor's phone number
Trusted friend, adult, or mentor — full name
Trusted friend, adult, or mentor — phone
What would you like to learn/experience on this trip?
Trusted friend, adult, or mentor — email
Do you have asthma? Yes No
Do you have diabetes? Yes No
Do you have epilepsy? Yes No
Do you have a heart condition? Yes No
Do you have any dietary restrictions? No Yes — explain:
Do you have any allergies? No Yes — explain:
Are you currently taking any medications? No Yes — explain:
Do you have any disabilities? No Yes — explain:
Do you have any phobias or fears? No Yes — explain:
Have you had any past surgeries or injuries? No Yes — explain:
Are there any vitamins or supplements you take? If yes, for what reason? No Yes — explain:
Do you have any other medical conditions? No Yes — explain:
Have you had struggles with eating disorders? No Yes — explain:
Do you have any current or past addictions? No Yes — explain:
Have you had a history of using drugs? No Yes — explain:
Have you ever taken medication for or been diagnosed with a mental health issue? No Yes — explain:
Do you have trouble sleeping? No Yes — explain:
Height
Weight
Emergency contact #1 name
Emergency contact #1 relationship
Emergency contact #1 phone
Emergency contact #2 name
Emergency contact #2 relationship
Emergency contact #2 phone
How will you be paying the non-refundable application fee of $250? Additional details will be sent in a follow-up email.
Check sent through the mailOnline through Zeffy
I attest that the information provided is accurate, and I consent to participate in this trip, including the photo release.
Applicant signature
Date
I give permission for my child to take part in this trip, and I accept financial responsibility for trip fees and any medical care needed.
Parent/legal guardian printed name
Parent/legal guardian phone
Parent/legal guardian email
Parent/legal guardian signature
Date