Team Registration Form

Team Member Registration
Choose Your Team*
First Name*
Last Name*
Birthdate

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Email*
example@example.com
Mobile Phone Number*
Please enter a valid phone number.
By providing Island Impact Ministries with your email address and mobile number, you agree to receive occasional SMS text messages and emails; your mobile information will not be shared with third parties or used for marketing purposes. Go to https://islandimpact.net/contact-us to read our Privacy Policy.
Occupation
Lodging & Room Preferences

Please select your preferred room type. Requests are honored when possible but cannot be guaranteed.
Hotel Room Occupancy

Single*Double*Triple*Quad Occupancy
*Roommate Names (Shared rooms only)
Please list names exactly as they appear on the registration form.
Flight Information
Arrival Date*

MonthDayYear
Date
Arriving Airport*

Puerto Plata POPSantiago STIOther
Arrival Airline*
Arrival Flight Number*
Arrival
Arrival Time*

Hour Minutes

AM/PM Option
Departure Date*

MonthDayYear
Departing Airport*

Puerto Plata POPSantiago STIOther
Departure Airline
Departure Flight Number
Departure Time*

Hour Minutes

AM/PM Option
Medical Information
Allergies
Medications
Emergency Contact*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.
Additional Information
Each team member will receive one free team t-shirt upon arrival in the Dominican Republic. Choose your t-shirt size below.*

SmallMediumLargeX-LargeXX-Large

Use this section to purchase extra t-shirts. There’s no limit—you can order as many as you’d like. Be sure to include your desired sizes and quantities. Your shirt will be given to you when you arrive. Thanks for helping us plan ahead!

Island Impact team t-shirt Product Image

Island Impact team t-shirtChoose the size of your extra t-shirt when you order.

$12.00 QuantityChoose your t-shirt size

Total

$0.00

Payment Methods

Credit Card

Cash App Pay

Languages Spoken

EnglishSpanishHaitian CreoleOther
Write a paragraph about why you are joining this mission trip.
Please describe your skills and the role you will have on the team
Document Upload
Passport: Please upload a copy of your passport picture below. *

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Credentialing: Please upload a copy of your medical license if applicable.

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Liability Waiver
Liability Waiver: By participating in this event, you agree to release Island Impact Ministries from any liability. Please read the full waiver carefully before signing.*
Travel to a foreign country always involves a certain level of inherent risk. While Island Impact seeks to minimize these risks by providing you with clear information, there still remain certain risks such as: simple health related concerns due to ingested foods that might have been prepared improperly or that carry parasites, and security risks such as theft. You will be briefed on any particular risks we are aware of at the time of your trip. 

Signing this form releases Island Impact Ministries, their staff, and directors, from any liability towards your person or possessions.

Waiver
I recognize and understand that mission activity involves risk not encountered in every day life. With this understanding, I am willing to participate in all mission activities and be cooperative with Island Impact Ministries leadership. I covenant and agree to indemnify and hold harmless and do release, requite, and forever discharge Island Impact Ministries, their staff and directors in any capacity, for all damages, claims, and/or liability arising out of injury to myself or my possessions. With the knowledge and understanding of the foregoing, I 
am applying to participate in the upcoming short term mission to the Dominican Republic or Haiti.
I have read and agree to the liability waiver*

I agree
Liability Waiver Signature*

Clear
Should be Empty:

Team Member Registration

Lodging & Room Preferences

Flight Information

Medical Information

Additional Information

Payment Methods

Document Upload

Liability Waiver