This page may not work correctly in your current browser, Internet Explorer. We recommend changing to a more modern browser before viewing this page. We recommend Chrome, Firefox, Safari, or Edge. Mission Trip Payment Form Complete the form below to submit payment for your trip. Questions? Call Elizabeth, our groups coordinator, at 530-867-7208, or email her at trips@jesusinhaiti.org. We can't wait to have you in Haiti! Church Name/Group Leader Payment Options I would like to pay: $100 - Individual Trip Deposit (Payment 1/2) $525 - Individual Trip Balance (Payment 2/2) $625 - Individual Trip Fee (Full Payment) Specify other amount $100 - Individual Trip Deposit (Payment 1/2) $525 - Individual Trip Balance (Payment 2/2) $625 - Individual Trip Fee (Full Payment) Specify other amount Your Contact Information First Name: Last Name: Address: Address Line 2 City: State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Federated States of Micronesia Guam Marshall Islands Northern Mariana Islands Palau Puerto Rico U.S. Minor Outlying Islands Virgin Islands Armed Forces Americas Armed Forces Europe, the Middle East, an Armed Forces Pacific Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Territory Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory Province (Foreign) Zip Code: - Zip Suffix Email: Phone: Special instructions Enter your note here (optional): You will enter payment information on the next page. Click "Submit" to continue. Add me to JiHM’s e-mail update list—I want to receive stories of God at work in Haiti! (You can unsubscribe at any time.)
