Mission Trip Application Mission Dates * November 2024 January 2025 June 2025 November 2025 Name First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Phone * (###) ### #### Date of Birth MM DD YYYY Gender Male Female Other Employment Information Employer Job Title Professional Medical Designation MD/DO PA/CRNA/NP RN Medical, Other If you selected "Medical, Other", please describe: Specialty Professional (Medical) License Type Professional License Number License Expiration Date MM DD YYYY Are you a Student or Resident? Student Resident No School/University Attending? Degree/Program/Specialty Projected Completion Date MM DD YYYY Mission Trip Information Passport Number Issuing Country Passport Expiration Date MM DD YYYY Name(s) of anyone traveling with you: Spanish Proficiency No Proficiency Elementary Proficiency Limited Working Proficiency Full Professional Proficiency Native/Bilingual Emergency Contact Name Relationship Phone (###) ### #### Email Donation Fee: $500 * To ensure the continued success of our mission trips and the vital work we carry out, we kindly request a donation of $500 from each applicant. This contribution plays a crucial role in covering the various expenses associated with organizing and executing our trips effectively, such as travel arrangements, accommodation, supplies, and support for the communities we serve. Please use the "Donate" button at the top right of the website. I understand. Additional Comments If you have any questions or concerns, you can also email aid.via.action@gmail.com.
