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Missions Registration Form
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Sarstun Clinic
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Home > Medical Missions > Missions Registration Form

Missions Registration Form

Pay Your Mission Trip Fee

Click one of the buttons below to send your mission fee or deposit, using your PayPal account or a credit card:

$100 deposit

$800 full fee

Mission trip balance (fill in the appropriate amount)

Fields marked with * are required.

Mission Trip Date and Destination *

Name (as it appears on passport) *

Passport # *

Date of Birth *

Name you commonly go by *

Address *

City *

State *

Zip Code *

Home Phone *

Work Phone *

Cell Phone *

Your Email Address *

Occupation *

Employer

Employer's Address

City

State

Zip Code

Professional License Type and Number

Expiration Date

Medical/Nursing Specialty

Are you participating as a student? If so, give name of school or university:

Second Language

Fluency Level (Spoken)

1

2

3

4

5

Fluency Level (Written)

1

2

3

4

5

Third Language

Fluency Level (Spoken)

1

2

3

4

5

Fluency Level (Written)

1

2

3

4

5

Special Skills

Carpentry

Childcare

Cooking

Clerical

Electrician

Mechanical

Inventory

Musician

Plumbing

Painter

Cleaning

Lab Technician

Other

Felony Criminal Record (please explain)

Personal Reference (Name) *

Relationship *

Phone *

T-Shirt Size (Unisex)

S

M

L

XL

XXL

XXXL

How did you hear about Refuge?

Have you been on mission trips before? If so, where?

I am also interested in being a Refuge volunteer in the following areas:

Collecting Medical Supplies

Clerical Assistance

Fundraising

Medical Conditions

Current Medications

Allergies or Special Diet

Blood Type

Emergency Contact/Beneficiary *

Relationship *

Phone *

Email Address *

Health Insurance Company *

Policy # *

Insurance Company Phone *

Please indicate if you would like to stay an extra night at an additional cost of $75.

Yes

No

Please review the information about the Change the World program and start raising funds today!

Amount of your goal for the Change the World program

Send a copy of this message to yourself

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