Short-Term Independent Service (2 weeks to 6 months)
Long-Term Health Missions Service
International Job Placement
Service Dates Requested
Service Destination Preference
Personal
(please type or print clearly as it appears on passport)
Title:
Mr.
Mrs.
Ms.
Miss.
Dr.
Rev.
Sex:
Male
Female
Name:
Suffix (RN, MD, CNA, etc.):
Street, Apt., etc. (both PO Box and physical address)
City:
State:
Zip:
Email:
Address:
Work Phone:
Home Phone:
Cell Phone:
Occupational
Place of Employment:
Occupation:
Street:
City:
State:
Zip:
Have you ever traveled outside your home country?
Yes
No
Have you previously been on a Medical Mission's trip?
Yes
No
If So Where to and When?
With Whom?
How did you hear about the Christian Health Service?
Do you have a current passport?
What Country?
Where was it issued?
Expiration Date:
Number:
Marital Status:
S
M
D
W
Spouse's Name:
Age:
City/State of Birth:
Citizenship:
Country of Birth:
Medical Information
PMD:
Phone Number:
Health Insurance Carrier and Policy No.
Medications:
Allergies:
Do you have any major or chronic illnesses which may adversely affect you while serving? If so explain.
Have you had any medical problems in the last 6 months? If so explain.
Do you have any health problems involving dietary restrictions, medical needs, or other unique needs we should be aware of?
Is your tetanus up to date?
Yes
No
Date:
*Contact you family doctor and/or Public Health Dept. regarding precautions/immunization required for travel to your destination.
Education Background
Please summarize your education/vocational background:
Emergency Contact Information
Must be parent or "Legal Guardian" if under 18
Name:
Relationship:
Address:
City:
State:
Zip:
Home Phone:
Cell Phone:
Alternative Emergency Contact
Name:
Relationship:
Address:
City:
State:
Zip:
Daytime Phone:
Cell Phone:
Gifts/Experiences
What Languages do you speak?
Please indicate any Skills, Talents, Spiritual Gifts or Christian ministry experience that you feel may be helpful on the field.
Health/Medical Training and Expertise:
Years of experience in health related field?
Pediatric Experience?
Yes
No
References (please provide 2 references. one should be a ministry leader)
1. Pastor
Church Address:
City:
State:
Zip:
Phone Number:
Email:
Years Acquainted:
Reference #2
Name:
Relationship:
Address:
City:
State:
Zip:
Phone:
Email:
Years Acquainted:
What Church/Fellowship do you attend and how often?
How long have you been going there?
List Ministries you are involved in:
Signature:
The Christian Health Service Corps is a Christian Medical Missions program and requires all those who serve members to commit willingly: follow the directive of the leaders or organization to which they are assigned, to faithfully conduct themselves in a manner worthy of the Lord while serving, and to refrain from any behavior which may compromise the witness of the team (i.e. sexual immorality, abusive language, use of drugs or alcohol et.). If you agree to these commitments please sign below, and attach no more than a one page summary of why you feel called to serve?
Note: If Applicable, your funds for your service time are your personal responsibility and need to be deposited with The Christian Health Service Corps by the deadline date given in the mailings that you receive.
