Trip Request Form – Vision Outreach International

Trip Request & Approval Form

Following is a brief questionnaire designed to help us help you. Your participation in this effort provides the groundwork for synergy, partnership, and effective communication. Please read the following information, check all that apply, and give us as many details as possible. Thank you!

Today's Date *

Your Name *

First

Last

Your Email *

Your Phone Number *

Trip Destination Name *

Name of Destination

Basic Trip Information – Starting Date – AND – Ending Date *

Location Street Address

Trip City, State , Zip / Province / Region

Trip Country *

"In Country" Contact Information or Associate *

First

Last

Who is organizing this event “IN COUNTRY?”

Organizer's Email *

Organizer's Phone Number *

What type of TRIP are you planning *

MSICS Training
Primarily Cataract Surgery
Optical & Screening
Combination

Please give a brief description of your mission and objectives. *

Please list all trip participants and their skills / OR list the types of SKILLS NEEDED *

Projected Cost Per Individual *

Estimated Number of Surgeries *

Define if you are doing screening or other procedure as your primary service.

Primary Needs and Other Information *