July 2024 Trip Application
Team Member Requirements & Code of Conduct
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I have read Caring Partners' Statement of Faith and Team Member Requirements 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. *
Full name as shown on passport:
(First Name, Middle Name, Last Name)
 *
Name you preferred to be called, if different from above:
(ex. Bill instead of William, Katy instead of Katherine, etc.)
Medical/Professional Specialty:
(Please include correct abbreviation: MD, RN, PharmD, etc.)
Medical/Professional Specialty State & License Number:
If you are still in school, Area of Study:
Mailing/Shipping Address (ALL Team Members):
(Out of state Team Members: Trip materials will be mailed to you approximately 1 week before the final team meeting. Please list an address where you will be for the meeting.)
 *
Phone Number: *
Email: *
Date of Birth: *
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Place of Birth: *
Passport Number:
(If you are in the process of applying/reapplying, please type APPLYING as your answer.)
Please email a color copy of your passport to office@caringpartners.org.
 *
Issue Date:
(If applying/reapplying, enter today's date.)
 *
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Expiration Date: Must be valid for a minimum of 6 months from the RETURN date of the trip.
(If applying/reapplying, enter today's date.)
 *
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Preferred Airport: If you will be traveling from a state other than Ohio, please list the airport you would like to use.
(Ohio team members usually fly in and out of Dayton or Cincinnati, occasionally, Columbus.)
 *
Frequent Flyer Number:
(Please include the airline: American, Delta, United, etc.)
Glove Size: *
Do you have your own stethoscope to bring on the trip or would you like CPI to pack one for you? *
Do you have your own BP cuff to bring on the trip or would you like CPI to pack one for you? *
Scrub Shirt Size:
(If you already have 4 or more CPI scrub tops, please choose the "No Scrub Top Needed" option.)
 *
T-shirt Size: *
Church's name, address, phone number, and the Pastor's name of the church you are currently attending:
(If you are not currently attending a church, please call Caring Partners at 937-743-2744 for additional instructions.)
 *
Leadership positions you hold:
(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 medications? *
If yes, please list the medication(s):
Do you have any dietary restrictions or allergies? *
If yes, please explain:
(Vegetarian, Gluten-free, Allergies, etc.)
Please provide the name and phone number of a person to notify in case of emergency:
(Provide the name of a person that will be in the United States and not traveling with you during your trip.)
 *
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