Visit Kijabe – Friends of Kijabe

Name

First Name

Last Name

Phone

What’s App (messaging/calls) can link to your mobile phone number, great to set this up before your visit.

Personal Email

Hospital/University email addresses often block messages from Kijabe.

Work Email

Mailing Address

Address, City, State, Zip

Emergency Contact

Please include Name, Phone, Email

Name of Sending Organization

Mission Agency, Academic Institution, Self

Name of Medical Practice/Training Program

If different from sending organization

Planned Visit Dates

Medical Specialty/Training Status

How did you hear about Kijabe Hospital?

Any particular goals/hopes for your time in Kenya?

Anything we can do to make your experience amazing?

Would you consider doing a fundraiser ahead of your trip?

Yes

No

Maybe (tell me more)

T-Shirt Size

Would you like to receive weekly emails from Friends of Kijabe

Yes

No thanks