COHS Medical Mission Trip Interest Form

Mission Interest Form

Please fill in the form below if you are interested in participating in future COHS Medical Mission Trips in any capacity or if you have a suggestion for a potential partnership serving domestically or internationally.
Full Name*

PrefixFirst NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
E-mail*
You Are: *

FacultyStaffAlumniCommunity Partner
Interested in (mark all that apply):*

Florida Domestic Medical Clinic (Spring Break)Guatemala Health Talents International (Spring Break)Honduras Predisan Health Ministries (Summer)Malawi Blessings Hospital (Summer)Guatemala Health Talents International (Summer)I'm unsure, please contact me.Other
Faculty, Staff, Alumni or Community Partner

Information
Company or College *
Years of Service*
Healthcare Credentials (if applicable)
Years in Practice
Specialty area(s)
Currently licensed?*

YesNoOther
Previous Mission Trip(s) (if applicable)
Mission Trip Role(s) (team member, leader, etc)
Leadership Interest (Check all that apply)*

Primary Leader (liaise with Missions & host partner)Co-Leader (assist with planning, training & trip support)Leader in-training (serve and supervise students)Team Member (serve as a practitioner)Unsure, I need more information.Other
Suggestion for new trip/host partner (if applicable)
Church Membership*
Briefly describe your interest in medical missions through a faith-informed lens*
Resume (optional)

Upload a File

Cancelof
Do you have a valid passport*

YesNoOther
Passport (pdf or jpeg)

Upload a File

Cancelof
Also interested in serving as a COHS student mentor*

YesNoUnsure, please provide more information.
How did you learn about COHS Mission Opportunities?*

Friend/ColleagueMissions FairWebsiteOther
If other, specify
Interested in receiving the COHS newsletter*

YesNo
Should be Empty:

Mission Interest Form

Faculty, Staff, Alumni or Community Partner