Team Registration Form

Island Impact Ministries

Team Member Registration Form
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
Languages Spoken

EnglishSpanishHaitian CreoleOther
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

Emergency Contact*

First NameLast Name
Emergency Contact Phone*
Please enter a valid phone number.
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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Arriving Airport

Puerto Plata POPSantiago STI
Arrival Date

MonthDayYear
Date
Arrival Time

Hour Minutes

AM/PM Option
Arrival Airline
Arrival Flight Number
Arrival
Departure Date

MonthDayYear
Departure Time

Hour Minutes

AM/PM Option
Departure Airline
Departure Flight Number
Write a paragraph about why you are joining this mission trip.
Please download, print, sign and return this liability waiver to: contact@islandimpact.net.
Should be Empty:

Island Impact Ministries

Payment Methods