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BMM - Jamaica Mission Trip Application Form
Thank you for your interest in traveling with Bethesda Medical Mission (BMM) to provide FREE medical and dental services to support Hurricane Melissa relief on the island of Jamaica in August 2026. Please complete this form by May 15, 2026.
Contact (860) 243-5569 or email bethesdamedmission@gmail.com for immediate questions.
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First Name
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Your answer
Last Name
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Your answer
Date of Birth
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MM
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DD
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YYYY
Email
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Your answer
Cell Phone number
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Your answer
Home Phone
Your answer
Mailing Address
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Your answer
T-Shirt Size
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Choose
S
M
L
XL
XXL
3XL
4XL
OCCUPATION INFORMATION
Industry
Medical
Dental
Pharmacy
Construction
Human Services
Education
Student
Retired
Nurse
Other:
Clear selection
Specialty
Your answer
Professional License Type/ State and Number/Expiration Date
Your answer
Areas of Interest to serve on trip (check all that apply)
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Medical care
Dental care
Eye care
Kids Zone (Vacation Bible School / VBS)
Logistics / General support
Pharmacy
Nutrition
Administration/Clerical
Other:
Required
PASSPORT INFORMATION
Provide information as it appears on your passport. If you do not currently have a passport, we recommend that you apply for an expedited passport immediately. Please send a photo from your passport to bethesdamedmission@gmail.com
Are You a U.S. Citizen?
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Yes
No
Other:
Do you have a current US Passport?
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Yes
No
Applying to renew
Other:
Passport Number
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Your answer
Expiration Date
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MM
/
DD
/
YYYY
Name as it appears on Passport
*
Your answer
TSA/Pre check/Global entry/Redress number etc...
*
Your answer
HEALTH INFORMATION
Medical Insurance Provider
Your answer
Policy #
Your answer
Allergies
Your answer
Any dietary restrictions?
Your answer
Any physical restrictions?
Your answer
Are you taking any Medication(s)? Please list
Your answer
Other than English, do you speak any other languages?
Your answer
Religious Preference (optional)
Your answer
EMERGENCY CONTACT INFO
Provide two emergency contacts
Emergency Contact #1 - Full Name
*
Your answer
Emergency Contact #1 - Relationship
*
Your answer
Emergency Contact #1 - Phone Numbers
*
Your answer
Emergency Contact #1 - Email Address
Your answer
Emergency Contact #1 Mailing Address
Your answer
Emergency Contact #2 - Full Name
Your answer
Emergency Contact #2 - Relationship
Your answer
Emergency Contact #2 - Phone Numbers
Your answer
Emergency Contact #2 - Email Address
Your answer
Emergency Contact #2 Mailing Address
Your answer
MISSION WORK
Have you previously been on a mission trip?
If so, when and name of group/organization
Your answer
What skills, gifts, expertise or experiences do you feel you can contribute on this mission trip?
Your answer
How did you hear about this Mission Trip? (check all that apply)
Website
Social Media
Friend
Colleague
Church
Printed Flyer
Word of Mouth
Other:
Questions or comments
Your answer
ACKNOWLEDGEMENT
I agree that everything in this application is completed truthfully. I wish to participate in this short term mission project and will uphold all guidelines and requirements set forth by my sponsoring organization, Bethesda Medical Mission.
I acknowledge that by submitting this form, I release Bethesda Medical Mission from any or all liability resulting or arising from my trip.
I understand that this release is binding to my peer executors and next of kin.
(Type name as digital signature)
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