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Medical Missions Program Grant Application


Fairview Sponsored Program:
Latin America
Africa

Please complete all sections of this application. Incomplete applications will be returned to the applicant, which may result in processing delays.

Destination Country: Medical Mission Trip Dates: (mm/dd/yyyy)
to
Name:
Street Address (Home):
City, State, Zip:
Home Phone:
(xxx-xxx-xxxx)
Work Phone:
(xxx-xxx-xxxx)
Cell Phone:
(xxx-xxx-xxxx)
Fax:
(xxx-xxx-xxxx)
Email:
Fairview Relationship Status
Hospital/Clinic affiliation Years at Fairview
Employee (20 hr/wk min.)
Clinical Hrs per week
Non-clinical Hrs per week
Position at Fairview
Department
Fairview Volunteer (50 hr/yr min.)
Retiree
Physician Associate
Financial Information

A financial grant will be awarded upon availability of funds.

Proposal Summary

Please describe this medical mission in narrative format, including:

  • Your personal goals
  • Your professional goals
  • Your responsibilities as a medical mission participant
  • Your motivation for being a volunteer
Liability Release

The Fairview Foundation provides funding for employees, volunteers, retirees and affiliated physicians and dentists of Fairview Health Services to participate in overseas medical mission projects. Fairview has no legal obligation for the safety of the individual participant either from an accident, armed conflict, natural disaster or other cause for any reason. The Fairview Foundation does not pass judgment on the medical needs of the particular community designated for a mission trip, nor does it provide information regarding current political and safety conditions of a country or destination. Accordingly, acceptance of a financial grant for a medical mission project, if offered, releases the Fairview Foundation and Fairview Health Services from any and all liability with respect to this medical mission project.

If you'd like a copy of your application for your records, please print it out before you hit "Submit." Longer responses in some text boxes may not show up in their entirety when you print from this form.