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) *
Your answer
Date of Birth *
MM
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DD
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YYYY
Phone Number *
Your answer
Email *
Your answer
Permanent Address (including zip code) *
Your answer
Profession/Occupation (if student, write student) *
Your answer
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:
Your answer
What do you hope to experience on this trip? (i.e. specific cultural experiences, cuisine, excursions, locations to visit, etc?) *
Your answer
What are your FAVORITE candies? (ideally some that are not chocolate as well) *
Your answer
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 *
Your answer
Contact 2: Name and Email *
Your answer
Contact 3: Name and Email *
Your answer
Contact 4: Name and Email
Your answer
Contact 5: Name and Email
Your answer
Contact 6: Name and Email
Your answer
Contact 7: Name and Email
Your answer
Interests during the trip (check all that apply): *
Required
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