General information

Name
(individual)

Name of group

Contact
person
(if different than above)

Address

City

State

  Postal code

Phone
(office)

Phone
(home)

Cell

E-mail

Select work week

I/Group will come the week of November 2, Beaumont, Texas

I/Group will come the week of November 9, Beaumont, Texas

Approximate number in group:
Youth must be at least 16 years of age to work with Habitat.

Final information

We must receive payment by the trip deadline (posted above with trip date). Earlier is better. Make checks payable to Disciples Home Missions. Send payment to: Office of Disciples Volunteering; P.O. Box 1986; Indianapolis, Ind. 46206.
I have read and understand the above statement.