ISLAND IMPACT MINISTRIES
APPLICATION FOR SHORT TERM
MISSION
SERVICE
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 Preference
#1 SBH #2 SBTS
T-Shirt Size:
S,M,L,XL,XXL,XXXL
Hotel Plan:
Room Type
Name of Home Church:
(If applicable)
Medical Questionnaire:
Please check all known medical conditions.
Heart Disease:
High Blood Pressure:
List all Allergies and
Medications
Diabetes
Respiratory Illness:
Epilepsy
Mental Illness:
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.
It is important that you
complete
the Waiver Forms and return them to your Group Leader to be sent to:
I
sland Impact Ministries
PO Box 6324
Stuart
, F
L
349
9
7
772-324-8253