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:
Interested in (mark all that apply):

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?

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

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

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Do you have a valid passport

Other
Passport (pdf or jpeg)

Upload a File

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Also interested in serving as a COHS student mentor
How did you learn about COHS Mission Opportunities?
If other, specify
Interested in receiving the COHS newsletter
Should be Empty:

Mission Interest Form