| Your Name:* |
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| e-mail:* |
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| User Name:* |
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| Password:* |
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| Verify Password:* |
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Personal Information
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| 7-Second EMail Update & Special Email Notification |
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| Address |
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| Address 2 |
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| City |
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| State |
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| Zip/Postal Code |
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| Country* |
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| Special skills/abilities/interests: |
Check all that apply. |
| Time Zone |
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| Primary Phone* |
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| Secondary Phone 1 |
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| Secondary Phone 2 |
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| T-Shirt size* |
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| Birthdate* |
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| Gender* |
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| Emergency Contact Name* |
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| Emergency Contact Phone* |
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| Alternate Emergency Phone |
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| Relationship to Emergency Contact |
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| Alternate Email Address |
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| Current Job Title |
Your current title in your line of work. |
| Local Church Name* |
Select the church that you would call your primary home church. |
| If other, please specify church name: |
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| Church District |
What district is your home church located in? |
| Health Issues |
Please provide any information about health issues that you have had or have that we need to be aware of. |
| Allergy Description |
If you have alergies, please describe |
| Special Food Needs |
Do you have any special food needs that we need to be aware of? |
| US Mail Newsletters & Special Mailings |
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Passport Information
If you will be traveling to our next Extreme event, please provide information regarding your travel. This will enable us to plan for your arrival and transportation on the ground. If you don't provide this information prior to traveling, you may not be picked up at the airport (not good for you!).
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| Passport Status* |
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| Passport Expiration Date |
Date your passport expires (DD-MM-YYYY) |
| EXACT Name on Passport |
How is your name spelled EXACTLY on your passport? |
| Issuing Country of Passport |
The country your passport was issued from. |
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Register For Extreme Peru
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| Register me for Extreme Peru* |
If you check "No" please skip to the last 2 questions in this section. |
| Project to Participate In |
Select The Project You Would Like To Participate In. |
| Second Project (Optional) |
If you would like to participate in a second project, please select from this list. |
| Third Project (Optional) |
If you would like to participate in a third project, please select from this list. |
| Preferred Area of Service |
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| Spanish Proficiency |
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| Portuguese Proficiency |
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| Payment Method |
A Customer Service Agent will follow up with a phone call to set up your desired payment method. |
| Payment Plan |
INSTANT 2% DISCOUNT APPLIES TO ALL PAYMENT METHODS IF BALANCE IS PAID IN FULL AT TIME OF REGISTRATION! |
| Contact me about becoming a Long Term Volunteer |
Please contact me about becoming a Long Term (3 mo. +) Volunteer with Extreme. |
| Conatact me about becoming a 40/40 missionary |
Please contact me about becoming a 40/40 (2 yrs.) missionary in Peru. |
