Registration Form EmailPassword*Enter PasswordConfirm PasswordNameFirstLastAddressStreet AddressAddress Line 2CityState / Province / RegionZip / Postal CodeAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayNorthern Mariana IslandsOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabweCountryPhoneReason For RegistrationYou are a mission group that would like to request equipmentYou are a mission group that would like to register (not currently requesting equipment)You are a developing program and would like to request equipmentYou are a developing program and would like to request a mission tripYou would like to donate equipmentYou would like to volunteer for help at CHIMS Mission Group Requesting EquipmentName of Mission Group / InstitutionSpecialty of Contact PersonCardiologistCardiac SurgeonPhysician AssistantNurseNurse PractitionerTechnicianSonographerOtherInstitution / OrganizationCurrent mission trip locationsAdditional mission trip locationsAdditional mission trip locationFrequency of mission tripsNumber of members in the missionDoes the mission include a cardiac surgeon?YesNoInventory Needed - DeviceSpecify DeviceQuantity0123456789101112131415161718192021222324252627282930Is Expired (sealed but not re-sterilized) Equipment Acceptable?YesNoDo you have another device to add?YesNoSpecify DeviceQuantity0123456789101112131415161718192021222324252627282930Is Expired (sealed but not re-sterilized) Equipment Acceptable?YesNoInventory Needed - CatheterSpecify CatheterQuantity0123456789101112131415161718192021222324252627282930Is Expired (sealed but not re-sterilized) Equipment Acceptable?YesNoInventory Needed - WireSpecify WireQuantity0123456789101112131415161718192021222324252627282930Is Expired (sealed but not re-sterilized) Equipment Acceptable?YesNoInventory Needed - SheathSpecify SizeQuantity0123456789101112131415161718192021222324252627282930Inventory Needed - BalloonsSpecify TypeSpecify SizeQuantity0123456789101112131415161718192021222324252627282930Inventory Needed - OtherSpecify Other DeviceQuantity0123456789101112131415161718192021222324252627282930Is Expired (sealed but not re-sterilized) Equipment Acceptable?YesNoWould you like your contact information to be available for mission trips that are registered on CHIMS?YesNoPlease enter below any additional specific requests or pertinent information: Register Mission GroupName of Mission Group / InstitutionSpecialty of Contact PersonCardiologistCardiac SurgeonPhysician AssistantNurseNurse PractitionerTechnicianSonographerOtherInstitution / OrganizationCurrent mission trip locationsFrequency of mission tripsNumber of members in the missionDoes the mission include a cardiac surgeon?YesNoIf you are a mission group registering to the site, would you like your contact information to be available for entities requesting mission trips that are registered on CHIMS?YesNoPlease enter below any additional specific requests or pertinent information: Request EquipmentSpecialty of Contact PersonCardiologistCardiac SurgeonPhysician AssistantNurseNurse PractitionerTechnicianSonographerOtherName of Charity / Organization / InstitutionLocation of Charity / OrganizationCityState / ProvinceCountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayNorthern Mariana IslandsOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabweWould you like your contact information to be available for entities requesting mission trips that are registered on CHIMS?YesNoInventory Needed - DeviceSpecify DeviceQuantity0123456789101112131415161718192021222324252627282930Is Expired (sealed but not re-sterilized) Equipment Acceptable?YesNoDo you have another device to add?YesNoSpecify DeviceQuantity0123456789101112131415161718192021222324252627282930Is Expired (sealed but not re-sterilized) Equipment Acceptable?YesNoInventory Needed - CatheterSpecify CatheterQuantity0123456789101112131415161718192021222324252627282930Is Expired (sealed but not re-sterilized) Equipment Acceptable?YesNoInventory Needed - WireSpecify WireQuantity0123456789101112131415161718192021222324252627282930Is Expired (sealed but not re-sterilized) Equipment Acceptable?YesNoInventory Needed - SheathSpecify SizeQuantity0123456789101112131415161718192021222324252627282930Inventory Needed - BalloonsSpecify TypeSpecify SizeQuantity0123456789101112131415161718192021222324252627282930Inventory Needed - OtherSpecify Other DeviceQuantity0123456789101112131415161718192021222324252627282930Is Expired (sealed but not re-sterilized) Equipment Acceptable?YesNoPlease enter below any additional specific requests or pertinent information: Request Mission TripName of Charity / Organization / InstitutionSpecialty of Contact PersonCardiologistCardiac SurgeonPhysician AssistantNurseNurse PractitionerTechnicianSonographerOtherLocation of Charity / OrganizationCityState / ProvinceCountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayNorthern Mariana IslandsOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabweLocation for Mission RequestedCityState / ProvinceCountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayNorthern Mariana IslandsOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabweMission Dates RequestedMission Date From Mission Date To Do you need additional personnel?YesNoList personnel typeList personnel typeList personnel typeList personnel typeList personnel type Would you like your contact information to be available for Mission Groups that are registered on CHIMS?YesNoPlease enter below any additional specific requests or pertinent information: Donate EquipmentSpecialty of Contact PersonCardiologistCardiac SurgeonPhysician AssistantNurseNurse PractitionerTechnicianSonographerOtherInstitution / OrganizationInventory - DeviceSpecify DeviceQuantity0123456789101112131415161718192021222324252627282930Please indicate:Expired (sealed but not re-sterilized)Non-expiredWould you like to add another device?YesNoSpecify DeviceQuantity0123456789101112131415161718192021222324252627282930Please indicate:Expired (sealed but not re-sterilized)Non-expiredInventory - CatheterSpecify CatheterQuantity0123456789101112131415161718192021222324252627282930Please indicate:Expired (sealed but not re-sterilized)Non-expiredInventory - WireSpecify WireQuantity0123456789101112131415161718192021222324252627282930Please indicate:Expired (sealed but not re-sterilized)Non-expiredInventory - SheathSpecify SizeQuantity0123456789101112131415161718192021222324252627282930Please indicate:Expired (sealed but not re-sterilized)Non-expiredInventory - BalloonSpecify TypeSpecify SizeQuantity0123456789101112131415161718192021222324252627282930Please indicate:Expired (sealed but not re-sterilized)Non-expiredInventory - OtherSpecify DeviceQuantity0123456789101112131415161718192021222324252627282930Please indicate:Expired (sealed but not re-sterilized)Non-expiredPlease indicate any comments regarding donation or any questions VolunteerSpecialty of Contact PersonCardiologistCardiac SurgeonPhysician AssistantNurseNurse PractitionerTechnicianSonographerOtherSpecify OtherInstitution / OrganizationI'm available from: until: Do you have a valid and current passport?YesNoHave you volunteered in a mission before? If so, where and how long? Please provide a brief explanation of your duties and responsibilities.