Friends of Haiti Medical Mission Trip Application Form

INSTRUCTIONS:  Please complete this application form for consideration for the Friends of Haiti Mission Trip.

  •  Once complete, click the “Submit” button and your completed form will be emailed directly to Professor DeMuth.  
  • The application deadline is 4:00 p.m. on Monday, April 23, 2018. 
  • Please contact Professor DeMuth, Travel Course Facilitator at 920-433-6671, Office Room 231, or Ann Wasmund, Travel Course Administrative Assistant at 920-433-6628, Office Room 109, should you have any questions or concerns.


Please provide the following required information. 

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • APPLICANT INTENTION: Please respond to the following questions.

  • References:

    BSN, BSRS, BSDMS, and MSN Students: You will need to supply two Bellin College Faculty References. Please provide the faculty members with the Faculty Reference form found on the Travel & Service Learning Experiences page (due April 23, 2018) and the Reference Request Form and Procedure form (release). This form remains with the faculty member and can be found on the College’s website. Faculty Members do not have to write a letter of reference, they only need to complete the form and return it to Kathie DeMuth. RN to BSN Students: You will need to supply two references. One team facilitator/manager and one peer. Please provide the person’s with the RN to BSN Reference form (due April 23, 2018). These are to be scanned in and emailed directly to Kathie DeMuth. Applications will be reviewed by the Bellin College Travel Committee.
  • BSN, BSRS, BSDMS, MSN Students

  • RN to BSN Students Manager/Team Facilitator:

  • Peer:

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