MEDICAL KIT REQUEST FORM

Please submit your Kit Request and a Packing List at least SIX WEEKS prior to your Mission Trip.

Today's Date

YYYY

How were you referred to Caring Partners? Please explain in detail.

Person Completing Form

Requesting Church's Name

Requesting Church's Tax ID# / EIN#

Mission Pastor or Team Leader

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

US / Overseas Ministry Partner

Contact Person

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Physician on trip or at destination

Not required to receive a Medical Kit, only necessary to receive certain medications.

Physician's Email or Phone Number

Dates of Mission

Dates leaving and returning

Requested Date to Receive Items By

Country of Mission

City/Province of Mission

How will The Gospel be presented? (Romans 10:14)

What is the maximum weight of medical supplies the team can carry?

Please note, your Medical Kit will not exceed this amount.

SHIPPING INSTRUCTIONS: A representative from your Church must come to the Caring Partners warehouse to pick up your Medical Kit. If you are unable to do so, email or call the Caring Partners office, and we can make shipping arrangements for your Mission Team. Please inform CPI of the address where items should be shipped via UPS.