Article: What to Include in Your Group’s Application Form

Posted by Laura on October 13, 2009 Leave a comment (0) Go to comments

It is important to know the right information to ask from your prospective group members.  Below is a sample application form contributed by our friends at Children of the Americas.  Click here to download the form in a Word document.  

Applicant Information
Name as it appears on your passport: (Last, First, M.I.)        Degree:      Area of Expertise:       
Occupation:       Social Security Number:                     
Home Address:       City:       State:     Zip:      
Office Address:       City:       State:     Zip:      
How were you referred to Children of the Americas, Inc.?      
Office Phone:       Cell Phone:       Home Phone:      
Prefer to be contacted at:     Office       Home E-mail address:      
Besides English, other language(s) spoken & how fluent:                                   
Emergency Contact: Name:                                            Address:           Phone & / or Cell:      E-mail:      Relationship:      

Passport Information
Passport Number:       Expires:       Date of Birth:      

Mission Experience
Prior medical missions participated in, if any:       
What role(s) anticipated in other mission trips:      
Special skills & Interests:      

References
Reference(s) :      

Travel Information
Airport departure city:            Primary:              Secondary:                                            

Health Information
Health status:                                                                               Allergies:                            
Any activities unable to perform while on the mission with or without accommodation?  
Current medications:                                         

Other
Please include any other relevant information:       
T-shirt Size:  S    M    L    XL    2X    Other    

 

Please include the following with your completed application:

  • Signed waiver form 
  • Curriculum Vitae (physicians only) 
  • Recent photograph
  • Copy of current state medical  license  
  • Copy of passport

If the  Team Coordinator has the above mentioned information on file from previous mission trips, it is not necessary to resend the information.

Signature/Print Name:                                        /                                        

Return by mail to:  ________, or send completed application as an attachment to e-mail to ______________ at _____@__ .  Applications are due by __________.  Applicants will be notified of the status of their applications by  _____________.
                 

 

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