Medical Application

Medical Mission Team Member Application

The completion of the form below will enable Healing Nations to consider you for short-term ministry in a Christian mission setting.

All information entered is confidential and will only be shared with appropriate personnel.
Before beginning, you will need the names and email address of two references.
Be prepared to upload a color copy of your current medical license as well as your passport picture page (Any app such as CamScanner can capture the image on your phone and email it to you. Once you save the picture to your computer, you are ready to upload).
If you do not have a passport, or need to renew it, visit https://travel.state.gov/content/travel/en/passports.html. Fill out the appropriate form, make a copy, and scan to upload during this trip application process.

THIS IS NOT THE GROUP OR CHURCH TEAM MEMBER APPLICATION. PLEASE VISIT HEALINGNATIONS.NET/TRIP-APPLICATION TO APPLY FOR A GROUP OR CHURCH TEAM.

"*" indicates required fields

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General Information

Which team are you applying for?*

Name (as it appears on your passport)*

First Middle Last

Nickname (if applicable)

Date of Birth*

Month

Day

Year

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Email*

Gender*

Occupation*

Employer*

List your personal strengths:*

List your weaknesses:*

List some personal goals you would like to accomplish by participating in this project/trip:*

List church affiliation (if any) and describe your involvement:

Have you ever been arrested or charged with any criminal offense in any country?*

Yes

You will receive an e-mail from Healing Nations and Clear Investigative Advantage (CIA) requesting permission for a mandatory background check.

If yes, please explain:*

If you will be traveling with a spouse or child, please list their name(s) here:

Emergency Contact and Medical Information

As standard procedure, we require the following information from everyone participating on a trip with Healing Nations. This information will be kept confidential.

Do you have any medical conditions that you are currently being treated for? Do you take any prescription medications for any reason?*

Yes

Please list any conditions you are being treated for along with medications you currently take:

(Be sure to bring your allergy and/or prescription medications in their original containers)

Do you have any allergies?*

Yes

Please list allergies and allergy medication you take:

I understand that while THC & CBD products are widely available in the US, many other countries still consider them illegal substances. I understand that I will not be able to bring any vitamins, herbs, supplements, or medications that contain either THC or CBD with me on this trip*

I agree

Emergency Contact #1*

First Name Last Name

Relationship*

Phone*

Emergency Contact #2*

First Name Last Name

Relationship*

Phone*

References

Please list two references and let them know they will be receiving an e-mail from Healing Nations with a link to our reference forms. Your application is not considered complete until your references have completed their forms.

Recent Employer Reference*

First Name Last Name

Recent Employer Email*

Enter Email Confirm Email

Spiritual Leader or Peer/Friend Reference*

First Name Last Name

Spiritual Leader or Peer/Friend Email*

Enter Email Confirm Email

Passport

Please upload a color copy of pages 2/3 of your passport. If you have not yet received your passport, please upload a copy of your passport application. If you haven't yet applied for a passport, send your passport application to [email protected] as soon as you've submitted it.

Drop files here or

Accepted file types: jpg, png, pdf, Max. file size: 250 MB, Max. files: 2.

Scrub Top Size*

Glove Size*

Do you have any previous medical mission or international experience?*

Yes

If yes, please provide with whom you traveled, where you traveled and dates of travel.*

Will you be acting as a medical professional on this trip?*

Yes

What type of license do you currently hold?*

Current License Number:*

State Issued*

Expiration Date*

MM slash DD slash YYYY

Please upload a copy of your medical license:

Max. file size: 400 MB.

Have you ever had your medical license suspended or revoked?*

Yes

If yes, please explain the circumstances:*

How many years of experience do you have in your profession?*

Please list any specialties or skills:

Project Waiver, Crisis Policy, and Code of Conduct

Please read the document below in its entirety before signing and submitting your application. This form will be printable from the confirmation screen and confirmation e-mail. Please print a copy for your records.*

I agree to the Waiver, Crisis Policy, and Code of Conduct

Deposit Information

Upon signing this form, you agree to pay an initial deposit of $500 per applicant that is non-refundable. This deposit can be paid directly to Healing Nations unless you are a member of a church team in which case this deposit will be collected by your church.

Signature*

Must be signed by a parent or legal guardian if under the age of 18. By signing above, I declare that all information disclosed in this document is correct to the best of my knowledge. I have read and agree to the Project Waiver/Liability Release, Code of Conduct, and Crisis Policy and am in compliance with all documents and statements therein.

MEDICAL MISSIONS APPLICATION

Medical Mission Team Member Application

General Information

Emergency Contact and Medical Information

References

Project Waiver, Crisis Policy, and Code of Conduct

Deposit Information