Island Impact Ministries

Please contact Island Impact Ministries with questions or comments.

Phone: 772.324.8253

Fax: 877.842.6121

Mailing Address:

P.O. Box 6324

Stuart, FL 34997

Hours of Operation:

Monday thru Friday, 9 am – 5 pm, EST

CONTACT US

Name of Group and Dates Traveling:

Name of Applicant:

Street Address:

City:

State:

Zip:

Applicant Phone Number:

Applicant Email Address (required):

DOB:

Gender:

Your Current or Past Occupation:

Emergency Contact:

T-Shirt Size(S,M,L,XL,XXL,XXXL):

Hotel Preference (#1 SBH #2 SBTS):

Hotel Plan (Room Type):

Name of Home Church (if applicable):

Medical Questionnaire:
(Please check all known medical Conditions)

Heart Disease
Diabetes
Epilepsy
High Blood Pressure
Respitory Illness
Mental Illness

List all Allergies and Medications:

Special Skills (Computer, Music, Construction, Art):

Languages Spoken (Poor/Fair):

Please write a few lines telling us why you want to go on this mission trip:

ISLAND IMPACT MINISTRIES APPLICATION FOR SHORT TERM MISSION SERVICE

Island Impact Ministries | 772.324.8253

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