DECEMBER 13TH – DECEMBER 14TH, 2019
MISSION APPLICATION FORM
To begin your application process, please fill out the following form.
When stating applicant’s name, please submit your name as it appears on the passport. One registrant per form, please.
NOTE: A $300.00 non-refundable/non-transferable registration fee is required to begin processing of your application. Application MUST be filled out completely to process and secure your spot on the team.
Dates of the trip: December 13-14, 2019
Full name as it would appear on passport:
Your Air Ticket will be secured in the name you have given us above – PLEASE make sure spelling is exactly as it appears on your passport or TSA will not allow you to board the plane. PLEASE PRINT CLEARLY
MISSION APPLICATION FORM – page two
If you have done other Missions Trips before, please list where
Is this your first trip with Heart2Heart?
If NO – Please list the years you have served with Heart2Heart.
Please list any special skills you could contribute:
Health Field: (please click one)
============================ MEDICAL PROFESSIONS ONLY ===============================
Are you a Health Professions student?
checkbox* checkbox-802 id:HealthProfStudent "Yes" "No"]
Program type & Institution
If not, please give details:
Are you physically fit and free of medical conditions or disabilities that could limit your activities and/or prevent you (and others) from safely performing the volunteer services for which you are applying?
Are you currently taking any medications on a regular basis? If yes, please list all medications
MISSION APPLICATION FORM – page three
Please include a $300.00 application fee with your completed application. Pay Application Fee Here
Confirm that you have TYPED your name clearly AS IT APPEARS ON YOUR PASSPORT.
Have you filled out this Application COMPLETELY?
By Typing Your Name, You are Signing This Form: The typed name below represents your signature: