Destination

Please select the destination of the trip for which you are applying:

Full name as shown on passport:

First, Middle, Last

Name you preferred to be called, if different from above:

(ex. Bill instead of William; Katy instead of Katherine; etc.)

Medical/Professional Specialty/Area of Study:

Please include correct abbreviation: Doctor (MD), Registered Nurse (RN), Pharmacist (PharmD), Chiropractor (DC), etc.

License Number, if applicable:

Please select your Glove Size:

Required for Medical Professionals. Non medical people, please select N/A option.

Do you have your own stethoscope to bring on the trip or would you like CPI to pack one for you?

Required for Medical Professionals. Non medical people, please select N/A option.

Do you have your own BP cuff to bring on the trip or would you like CPI to pack one for you?

Required for Medical Professionals. Non medical people, please select N/A option.

Mailing/Shipping Address:

Trip materials are mailed to team members that are traveling from a different state. Please list an address where you can receive packages approximately 2 weeks before trip.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone Number and best time to call, if necessary:

Email Address

Date of Birth:

YYYY

Place of Birth:

Passport Number:

If you are applying or reapplying for a new passport, please type IN PROCESS in this section.

Issue Date:

If you are applying or reapplying for a new passport, please type any date in this section.

YYYY

Expiration Date:

If you are applying or reapplying for a new passport, please type any date in this section.

YYYY

Preferred Airport:

Local team members will fly in and out of either Dayton or Cincinnati Airports. If you will be traveling from a different state, please list the airport you would like to use for traveling.

American Airlines Frequent Flyer Number:

Delta Frequent Flyer Number:

United Airlines Frequent Flyer Number:

Scrub Shirt Size:

If you already have 4 or more CPI scrub tops from past trips, please choose the 'No Scrub Top Needed' option.

T-shirt Size:

Name & Address of Church Currently Attending: (If you are not currently attending a church, please call Caring Partners at 937-743-2744 for additional instructions.)

Pastor's Name:

Phone:

Leadership Positions you Hold:

E.g. Worship, Education, etc.

Are you on any regular medications?

If yes, please list the medication(s) and the condition(s) why you are taking them:

Are you allergic to any food or medications?

If yes, please list:

Do you have any dietary restrictions or other medical or physical limitations?

If yes, please explain:

In case of emergency, notify:

Please give the name of a person that is NOT traveling with you on the mission trip.

First Name

Last Name

Address:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone:

I have read Caring Partners’ Statement of Faith and Team Member Requirements (see previous page) for mission travelers, and I agree that I will adhere to these principles and standards during the mission journey. I have also read and understood the Refund Policy of Caring Partners International, and will abide by its requirements. In addition, the information I have listed on the Team Member Registration Form is accurate and true.

I agree

THANK YOU FOR SUBMITTING YOUR APPLICATION!

WITHIN 2 WEEKS, OR BY THE DUE DATE DESIGNATED BY YOUR TEAM LEADER, email/mail/deliver the following items to: office@caringpartners.org or 601 Shotwell Drive Franklin, OH 45005.
* A legible COLOR copy of the photo page of your signed passport.
* A copy of your medical license, if applicable.
* A deposit of $300.00. Please designate the trip name in the memo section of your check. (A spot can not be held until a deposit has been received.) If you would like to make your deposit with a credit card, click HERE. (Designate the trip name in the Comments section.) You may also call the office at 937-743-2744 and we can take your credit card information over the phone.