KANSAS 2 KENYA Team Application Please complete the following information and email it to the appropriate team leader. Mail the completed application, items noted below, and the deposit. Items Mail all to: Team Application Episcopal Diocese of Kansas --Select your team, fill out the application 835 S.W. Polk St --Email your team leader Topeka, KS 66612-1688 Complete the Consent document Attn: K2K Provide 2 copies of your Passport Provide your immunization record Send deposit with application: Deposit: $ 400 Due by December 15, 2017 Air: $ 1,500 Due by February 23,2018 Final: $ 1,400 Due by May 4, 2018 (Community) $ 1,600 Due by May 4, 2018 (Medical) Select your team: Team Dates Email to team leader Select Community Team (Cost: $ 3,800) June 7 20 – Medical Team (Cost: $ 4,000) June 14 27 – ---Pharmacy Group of Medical Team June 7 - 27 Personal Information: Name as it appears on your passport Date of Birth Gender M F Street Address City State Zip Primary Phone Secondary Phone Primary email Secondary email Passport Number Expiration Date Country Emergency contact Information: Emergency Contact Name Contact email Contact Phone Relationship
KANSAS 2 KENYA Team Application Please complete the following information and email it to the appropriate team leader. Mail the completed application, items noted below, and the deposit. Items Mail all to: Team Application --Select your team, fill out the application --Email your team leader Episcopal Diocese of Kansas 835 S.W. Polk St Topeka, KS 66612-1688 Attn: K2K Complete the Consent document Provide 2 copies of your Passport Provide your immunization record Send deposit with application: Deposit: $ 400 Due by December 15, 2017 Air: $ 1,500 Due by February 23,2018 Final: $ 1,400 Due by May 4, 2018 (Community) $ 1,600 Due by May 4, 2018 (Medical) Select your team: Select Team Dates Email to team leader Community Team (Cost: $ 3,800) June 7 – 20 Medical Team (Cost: $ 4,000) June 14 – 27 ---Pharmacy Group of Medical Team June 7 - 27 Personal Information: Name as it appears on your passport Date of Birth Gender M F Street Address City State Zip Primary Phone Secondary Phone Primary email Secondary email Passport Number Expiration Date Country Emergency contact Information: Emergency Contact Name Contact email Contact Phone Relationship