Student InformationStudent First Name(Required)Student Last Name(Required)Student Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Student Cell Phone(Required)(This number will be used by chaperones to communicate with students while in D. C.)Student Email Address(Required) Enter Email Confirm Email Student Date of Birth(Required) MM slash DD slash YYYY Sex of Student(Required) Female Male Student Sweatshirt Size (Adult Sizes)(Required) Small Medium Large XLarge XXLarge Friends Attending (For making chaperone groups)Grade in School(Required) Sophomore Junior Senior Student Home church(Required)Student's Youth Pastor Name and Contact Info (or pastor if you do not have a youth pastor)(Required)Please include email and phone number. We will contact your youth pastor or pastor for a reference.Emergency Contact Name and Phone Number(Required)Physician Name and Phone Number(Required)Student AllergiesStudent Dietary RestrictionsParent Information, Release Form, and Billing InformationParent First Name(Required)Parent Last Name(Required)Parent Email Address(Required) Enter Email Confirm Email Release FormParent's first, middle initial, and last name(Required)Parent “Signature” – By entering my name above, I acknowledge that I am the parent or legal guardian of the above student and that I give him/her permission to participate in the Right to Life of North Central Indiana March for Life trip to Washington, D.C. I have read and understand the description of this event. I grant permission for emergency medical treatment on the recommendation of a medical doctor. I release Right to Life of North Central Indiana and Lakeland Christian Academy and all other sponsors, staff, and chaperones from any liability resulting from illness or injury. I agree to allow Right to Life of North Central Indiana to use photos and video taken of my child for marketing purposes.Payment Information Once you click 'Charge My Credit Card' your credit card will be charged.Cost Price: Fee includes a sweatshirt, 3 meals, overnight accommodations, chaperones, museum tickets, and travel on a charter tour bus. Your student will need extra money for 5-6 meals.Billing First Name(Required)Billing Last Name(Required)Billing Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Payment Method(Required)Credit Card American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Expiration Date Security Code Cardholder Name PhoneThis field is for validation purposes and should be left unchanged. Δ