Team Registration Form

Island Impact Ministries

Team Member Registration Form
Choose Your Team
First Name
Last Name
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState

Zip Code
Mobile Phone Number
Please enter a valid phone number.
Birthdate

MonthDayYear
Date
Occupation
T-Shirt Size

SmallMediumLargeX-LargeXX-LargeYou will receive one T-shirt with your registration. Click here if you want an extra T-shirt available for purchase at $10 each. Payment can be made in the Dominican Republic.
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