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Medical Mission Trip Application


Program: Country: Trip Dates: (mm/dd/yyyy)
Latin America
Africa
to
General Information
Name:
(as it appears on your passport)
Street Address (Home):
City, State, Zip:
Email:
Home Phone:
(xxx-xxx-xxxx)
Work Phone:
(xxx-xxx-xxxx)
Cell Phone:
(xxx-xxx-xxxx)
Profession:
License Number:
(if applicable)

Bring copy of license to 1st training meeting
Expiration Date: (mm/dd/yyyy)
U.S. Citizen? Yes
No
If no, country of citizenship:

Visa Status:
Passport Passport Number:

Bring copy of passport to 1st training meeting
Expiration Date: (mm/dd/yyyy)
Date of Birth:
(mm/dd/yyyy)
Medical Background/Experience

Briefly describe your medical training and experience. Include areas of expertise and preferred patient population.

Experience in Overseas Medical Work
Past Trip Location Year
Language Skills
Language Fluency
References
Name Relationship Phone
(xxx-xxx-xxxx)
Personal Medical Information

Major Illnesses:

Regular Medications:

Allergies:

Treatments/Hospitalizations:

Physical Limitations/Restrictions:

Blood Type:

Vaccinations
Vaccine Dates Given
Tetanus
Typhoid
Yellow Fever
Hepatitis A
Hepatitis B 1st
2nd
3rd

Unless your personal physician recommends otherwise, the basic immunizations we recommend are Hepatitis A, Hepatitis B, tetanus, typhoid, MMR (if needed), Varicella (if needed), and Malaria prophylaxis. Each traveler should check the CDC website at www.cdc.gov for the latest recommendations. It is your responsibility to ensure that you are properly vaccinated.

Insurance Information

Please consult with your insurance company about coverage overseas. Most insurers only provide coverage in the United States. Travel insurance and major health insurance will be provided for the duration of the trip.

Your current insurance company:
Your current policy number:
Beneficiary for travel insurance policy purchased for you:
Relationship:
Emergency Contact
Name:
Contact Relation:
Street Address:
City, State, Zip:
Email:
Home Phone:
(xxx-xxx-xxxx)
Work Phone:
(xxx-xxx-xxxx)
Cell Phone:
(xxx-xxx-xxxx)
Commitment

By this submission, I certify that I will read the Medical Missions Training Manual and understand the basic social differences and expectations as described in the manual. I understand that I may be working with a local church and agree to work within the social expectations of those with whom I am working. (The manual will be provided during the first training meeting.)

I also certify that, to the best of my knowledge, the above information is accurate.

I certify that to the best of my knowledge the above information is accurate. I understand that it is my responsibility to obtain appropriate immunizations and I assume all risk associated with travel overseas.

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.