Team Sign Up Form - Island Impact Ministries

Island Impact Ministries

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Team Sign Up Form

Name of Group & Dates Travelling: *

Name of Applicant *

First

Last

Street Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

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Email *

DOB *

Gender *

Occupation *

Hotel Room Plan: Single, Dbl, Triple, Quad: *

Island Impact T-Shirt Size: S,M,L,XL,XXL *

Name of Home Church (if applicable) *

Medical Questionnaire:

Check all known medical conditions that apply to you: *

Heart Disease Diabetes High Blood Pressure Respitory Illness Mental Illness Epilepsy Other - Please explain below

Medical Conditions - Other *

List all Allegeries and Medications currently taken: *

Emergency Contact Name *

First

Last

Emergency Contact Phone Number *

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

Languages Spoken (Poor/Fair): *

Do you sponsor a child with Island Impact? *

Yes No

What is your sponsor child's ID Code & Name? (If applicable) *

Would you be interested to learn more about Child Sponsorship? *

Yes No

Does your family or friends sponsor a child with Island Impact who you would be interested in meeting with during your mission trip? Please include the child's ID code and name. *

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

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Island Impact Ministries 772.324.8253