ISLAND IMPACT SHORT TERM TEAM PERSONAL ON LINE APPLICATION
Name of Group and
Dates Traveling:
Name of Applicant:
Street Address:
City:
Zip Code:
State:
Your email address:
Your phone number:
Required Field
DOB:
Gender:
Male;Female
Your Current or Past
Occupation:
Emergency Contact
Name and Address
and Relationship:
Hotel Plan:
Plan A;B;C
T-Shirt Size:
S,M,L,XL,XXL,XXXL
Name of Home Church:
If Alpplicable
Special Skills:
Computer, Music
Construction, Art
Languages Spoken:
Poor/Fair
Medical Questionaire: Please check all known medical conditions.
High Blood Pressure:
List all Allergies and
Medications
Heart Disease:
Diabetes
Respiratory Illness:
Mental Illness:
Epilepsy
Please write a few lines telling us why you want to go on this trip.
This form will be submitted directly  to the office in the Domincan Republic.  It is important that you fill out
the Waivers Form and turn it into your Group Leader to be sent to:

Robert and Kelli Nelson
Agape Flights SGO # 3981
100 Airport Road
Venice, Fl 34285  USA

Individual Applicants
Fill out the application below.
Then hit submit.
Island Impact Ministries

Contains all the information you need
to get ready for your upcoming trip.