Student Mission Trip Chaperone Form

Packing List & Dress Code
Volunteer Application
Participation Form
MS also requires a Background check every year. They will need to click THIS LINK to fill it out online. Once complete they will receive a confirmation email. That email must be forwarded to StudentMissionTrip@pccwired.net
You must have a valid PCC background check as well.

Are you interested in being a chaperone on the student mission trip?
Requirements listed below. Are you able to meet all of these requirements?*
-You must be over the age of 18. -You must submit a background check.
- Yes
- No
Name*
First Last
Email Address*
Phone*
T-shirt Size
If needed, are you willing to transport students?*
(A 15 passenger van will be provided. You must be at least 25 years old with a valid drivers license.)
I will pay this via:*
The cost for chaperones is $200. This will cover your food and lodging, as well as the free day activity. Payment can be made now or after background check & training are completed.
PAYMENT Information:
Please make checks payable to PCC On the memo line please include: Columbus County, NC Mission Trip & your students name
Checks may be mailed to PCC Attn: Ellis Hopson PO BOX 834, Powhatan VA 23139
After completing your registration, you’ll receive an email with a link to make an online payment if you haven’t paid in full.

PAPERWORK Information:
Paperwork must be completed for each student
Be sure to have Participation form notarized if your student is under 18
Once complete, return to your campus Student Coordinator or mail to PCC Attn: Ellis Hopson PO Box 834, Powhatan VA 23139

You may also submit checks:

Via mail to
PCC
Attn: Ellis Hopson
P.O. Box 834
Powhatan, VA 23139
Thank you for your interest!
Payment Method

MasterCard
Visa
Supported Credit Cards: MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name