MIMA Foundation Trip Application

NAME:

 

ADDRESS, PHONE & EMAIL:

 

EMERGENCY CONTACT:

 

ALLERGIES OR MEDICAL CONDITIONS:

 

DO YOU SPEAK SPANISH?

 

HOW DID YOU HEAR ABOUT MIMA?

 

 

ARE YOU AWARE THAT YOU ARE RESPONSIBLE FOR BOOKING YOUR FLIGHT AND CONTRIBUTING TO THE LAND PORTION OF YOUR TRIP?  

 

PLEASE SEND RESUME, CURRENT LICENSES & COPY OF PASSPORT WITH THIS APPLICATION.

 



Please print this form, complete, and mail or email to :

MIMA Foundation
P.O. Box 7133
Jupiter, FL 33468-7133
Phone: 561-747-3334

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