Please fill out this form completely in order to let us know about a community that might benefit from the type of work we do.

PLEASE NOTE: In order for us to effectively use our limited resources and to better help the proposed community, we require that there be a person/persons or an organization from that area dedicated to helping to facilitate arrangements on our behalf.

NAME, first:

NAME, last:

Email address:

Mailing Address:

Please describe the community served
Who is being helped?

Please describe how you are connected to this community:

Do you have a time frame in mind for the proposed mission?:
When would be a good time for this mission?

What potential resources (hospitals/clinics/NGO's/medical schools, etc) are located in the proposed region?:

Other Information:

How did you hear about ISHI and why do you want to work with us?:

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