Urban Immersion

Urban Immersion
August 4-10, 2019
Youth entering Grades 7-9

* Registration for this trip is limited to 20 youth.

Cost $500

This year’s Urban Immersion trip will be hosted by Sierra Service Project – San Diego. We will be staying and serving in Imperial Beach. Youth will focus on poverty, immigration, and the environment. There will be the opportunity to ask questions and broaden our world view.

SSP does half of their work with homeowners, and half with community-based organizations. The type of work includes painting, rebuilding fences, and other general home repairs. No construction experience is needed, and you’ll be amazed at all the work our teams complete! Since we will be the final program week, we anticipate having the opportunity to finish many of the projects that are started over the summer.

Registration for this trip is limited to 20 youth. Once the trip is full, we will begin a fundraising effort. It is our hope, that youth will be able to raise the majority of the money needed for their trip.

Steps to Successful Event Registration

1. Complete the waiver form below and click Submit.
2. Register and make your $50 deposit using the link below.

Ta Dah! That’s it! You’re done!

Please contact youth missioner, Charlette Preslar with any questions, cpreslar@edsd.org

Urban Immersion - Youth Waiver

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Participant Name *

Participant Email *

Birth Date *

Grade (open to 7th through 9th) *

Signature of Parent or Legal Guardian *

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Name of Parent of Guardian *

Date *

Emergency Contact Information

Parent/Guardian(s) Name(s) *

Street Address *

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Email Address *

Additional Email Address

Phone Number *

Phone Type *

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Additional Phone Number

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Other Emergency Contact Name

Relationship to Participant

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Health Care Information

Physician Name *

Phone Number *

Medical Insurance Company *

Policy/Group Number *

Name of Policy Holder *

Please list any allergies to drugs, foods, plants etc.:

Please list any prescription medication to be taken by the participant (including what it is taken for, when it is to be taken, dosage information, and any special procedures):

Please list any non-prescription (over-the-counter) medication you do NOT want dispensed to your child:

Please list any additional information relevant to participating in Youth Group activities (dietary needs; surgeries or serious injuries; chronic or recurring illness; medical conditions such as epilepsy or diabetes; psychiatric counseling or indications, etc.):

You have received this parental consent form to both inform you and to request your permission for your child’s photo/image and name to be published edsd.org and/or any other websites maintained, owned, and/or administrated the Episcopal Diocese of San Diego. The law requires that we ask for your permission to use information about your child. Pursuant to law, we will not release any personally identifiable information without prior written consent from you as parent or guardian. Personally identifiable information includes youth names, age, grade, and photo or image. If you, as the parent or guardian, wish to rescind this agreement, you may do so at any time in writing by sending a letter to the Youth Collaborative Missioner, Charlette Preslar, and such rescission will take effect upon receipt.

Check one of the following choices:

I/We GRANT permission for this youth’s photo/image and all other personal identifiers listed above to be published on the Episcopal Diocese of San Diego public website or any site operated by the Episcopal Diocese of San Diego

I/We GRANT permission for ONLY a photo/image that includes this youth without any other personal identifiers to be published on the Episcopal Diocese of San Diego public website or any site operated by the Episcopal Diocese of San Diego.

I/We DO NOT GRANT permission for photo/image that includes this youth to be published the Episcopal Diocese of San Diego public website or any site operated by the Episcopal Diocese of San Diego.