Participant Interest Form
Name
*
First Name
Last Name
Email
*
example@example.com
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
*
Month/Day/Year
CBFNC Church Name:
*
Medical Profession:
*
Dentist
Dental Hygienist
Registered Nurse
Physician Assistant
Physician
Nurse Practitioner
Ophthalmologists
Optometrists
Optician
Other
T-Shirt Size
*
Small
Medium
Large
X-Large
XX-Large
XXX-Large
How did you hear about this opportunity?
*
Why are you interested in going on the Ecuador Health Mission Immersion?
*
Tell us about your previous missions experience:
*
What concerns do you have about the trip, travel, culture, or work?
*
At this time, which areas of service interest you most? (Check all that apply)
*
Dental Clinic
General Medical Clinic
Eye Clinic
Physical Therapy
Pharmaceutical
Other
What else do you want us to know?
*
Have you applied for a passport or checked your passport expiration date?
*
Agree
Do you agree to attend all team meetings, read the team guidebook, submit all paperwork and trip payments on time, and commit to bringing your best self to the mission immersion?
*
Agree
Are you interested in staying additional days in Ecuador for touring and adventures? The expected cost is $400.
Yes
No
Maybe
Have you mailed a $250 non-refundable deposit to CBF North Carolina, Attention: Ecuador Medical Mission Immersion, (Participant’s Name), 2640 Reynolda Road, Winston-Salem, NC 27106?
*
Yes
Submit
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