Island Impact - kflconversion - 12345

Team Member Registration Form

You will need a copy of your passport and medical license or certification to upload to your application to complete this form.

Choose Your Team

* First Name

* Last Name

* Email

* Address

* City

* State

* Postal Code

T-Shirt Sizes (Surgical teams receive caps)

* Birthday

* Mobile Phone

* Emergency Contact

* Emergency Phone

* Occupation

Credentialing

* Passport Number - (please enter the number in this field and upload a copy of your passport picture below)

Passport

Immunization Record

Medical Licensing

* Medical License Number - (please enter the number in this field and upload license below) If you are non-medical you can upload a copy of your passport again.

* Image

Travel Info

* Arrival Date

* Departure Date

After submitting this form, you will be redirected to a payment page to make your registration or hotel payment according to your team's name and prices.

Team Member Costs

Each Team must have a minimum of 15 people

1. Registration Fee -

Medical/Other Team - $300/per person for group of 15 people or more

Surgical Team - $360/per person for group of 15 people or more

2. Fee Includes

a. Local Transport -airport to hotel, outreaches, restaurants.

b. Credentialing with host country and Medical Authorities.

c. IIM surgical skull cap or Island Impact T-shirt. Extra t-shirts can be purchased for $15 ea. To place an order for an extra t-shirt, after registering, use the link on the payment page.

d. Patient recruitment and pre-op and post-surgical follow-up.

e. Shared translators

3. There is an additional fee of $50 per person, per day for stays > than 7 nights, or you can use local taxi services at your own expense.

4. We will make hotel reservations, however you are responsible for paying for your own room costs and R/T airfare.

5. Lodging Costs: You will be invoiced for the room cost. Hotel payment is expected in full when you receive the invoice.

6. Team is responsible for all surgical and medical supplies needed to fulfill their mission. Please ask for a list of meds that we use.