Student Information

Student Address(Required)
(This number will be used by chaperones to communicate with students while in D. C.)
Student Email Address(Required)
MM slash DD slash YYYY
Sex of Student(Required)
Student Sweatshirt Size (Adult Sizes)(Required)
Grade in School(Required)
Please include email and phone number. We will contact your youth pastor or pastor for a reference.

Parent Information, Release Form, and Billing Information

Parent Email Address(Required)

Release Form

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.
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 Address(Required)
Payment Method(Required)
American Express
Supported Credit Cards: American Express, Discover, MasterCard, Visa
This field is for validation purposes and should be left unchanged.

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