Forms

Panama 2023

Full Price of the Trip: $1500

• April 21st: Deposit of $200 is due
• May 26th: at least 50% of trip must be paid
• June 30th: trip must be 100% paid

Northeast Hispanic Region - Church of GOD of Prophecy

Price: $1,500.00

Name

Email

Phone Number

Age

Gender

Female

Male

Which COGOP Church do you attend?

Boston/ Jamaica Plain MAFall River MALawrence, MALynn MAPeabody MAProvidence, RISpringfield MAWorcester MAWoonsocket RIBridgeportEast HavenStamfordAmsterdam, NYBronx, NY (Bryan Ave.)Bronx, NY (Walton Ave)Manhattan, NYSpring Valley NYBrooklyn, NY (87 Montauk Ave.)Brooklyn, NY (487 South First St.)Brooklyn, NY (Fulton Ave.)Woodhaven, NY Jamaica Ave.Brentwood, NYNassau, NYHuntington Station NYOyster Bay/Hempstead, NYPort Jefferson, NYSea Cliff, NYBay Shore, NYFar Rockaway, NYHempstead/Freeport, NYNew Babilon, NYDover, NJHoboken, NJJersey City, NJJersey City, The Hub NJPassaic, NJPaterson, NJNewark, NJUnión/North BergenElizabeth I, NJ ( Elizabeth Ave.)Elizabeth II, NJ (Magie Av.)Morrestown, NJUnión, NJNew Brunswick, NJBrentwood, MDRandallstown, MDGeorgetown, DEBaltimore, MDMilford, DESilver Spring, MDFairfax, VAChesterfield, VAFrederickburg, VAHarrisonburg, VAManassas, VARichmond, VAWoodbridge, VAErie, PAGettysburg, PAPhiladelphia, PAWilkes-Barres, PAOtherN/A

Are you a member of the church?

Yes

No

Do we have permission to reach out to your local Pastor for a recommendation, if needed?

Yes

No

Are you a…

Church Attendant Church Member Lay Minister Pastor Bishop

Acknowledge Do you understand the cost of the trip is $1,500.00?

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