Myanmar Medical Mission Trip Application
Your spot is not secure until you have paid the deposit of $300 by November 15, 2019. If writing a check, please make it out to Be the Change Global Outreach.

Payment Option Details:
https://docs.google.com/document/d/1lyEBcf6W4o6-E5nM2gWa9W6FGtNuWB0g6ovpqFjZwXs/edit?usp=sharing
Full Name (as listed on passport) *
Date of Birth *
MM
/
DD
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YYYY
Phone Number *
Email *
Permanent Address (including zip code) *
Profession/Occupation (if student, write student) *
If a medical professional, please email a copy of your license to jbrewster.pharmacy@utexas.edu
What is your T-Shirt Size? *
How did you hear about this trip? *
Required
Have you ever been arrested for, charged with or convicted of any type of crime having to do with child molestation, sexual assault, rape, indecent exposure, or any sexual related offense? *
If yes, please explain:
What do you hope to experience on this trip? (i.e. specific cultural experiences, cuisine, excursions, locations to visit, etc?) *
What are your FAVORITE candies? (ideally some that are not chocolate as well) *
Family, Friends and Close Contacts
Please list below the names and email of some people who are close to you, have made an impact in your life, and/or dear friends and family. Please provide as many as possible. These do NOT have to be emergency contacts.
Contact 1: Name and Email *
Contact 2: Name and Email *
Contact 3: Name and Email *
Contact 4: Name and Email
Contact 5: Name and Email
Contact 6: Name and Email
Contact 7: Name and Email
Interests during the trip (check all that apply): *
Required
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