MIMA Foundation Trip Application
NAME:
ADDRESS, PHONE & EMAIL:
EMERGENCY CONTACT:
ALLERGIES OR MEDICAL CONDITIONS:
DO YOU SPEAK SPANISH?
HOW DID YOU HEAR ABOUT MIMA?
WHICH TRIP ARE YOU INTERESTED IN FOR JUNE, 2011?
June 9th June 16th
ARE YOU WILLING TO CONTRIBUTE OR RAISE $1350 TO OFFSET THE TRIP EXPENSES?
PLEASE SEND RESUME, CURRENT LICENSES & COPY OF PASSPORT WITH THIS APPLICATION.
Please print this form, complete, and mail or fax to: MIMA FoundationP.O. Box 7133Jupiter, FL 33468-7133Phone: 561-747-3334Fax: 561-747-2535
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