Medical Ministry Application

General Information

Name (as it appears on your passport)*

First Middle Last

Nickname (if applicable)

Date of Birth*

Gender*

Spouse Name (if applicable and as it appears on their passport)

First Middle Last

Spouse Nickname (if applicable)

Spouse Date of Birth

If you have children, please share their names and birthdates:

Phone*

Email*

Current Address*

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

Field Address (if applicable)

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

Employment & Education

Current Occupation & Employer*

Spouse Occupation & Employer

Current Employer*

If possible, please provide at least 5 years of employment history

Name Street Address City State / Province / Region ZIP / Postal Code Country

What is your role/position?*

How long have you been employed here?*

Reason for leaving? (if applicable)

Previous Employer #1

Name Street Address City State / Province / Region ZIP / Postal Code Country

What was your role/position?

How long were you employed?

Reason for leaving?

Previous Employer #2

Name Street Address City State / Province / Region ZIP / Postal Code Country

What was your role/position?

How long were you employed?

Reason for leaving?

Please list your educational background along with any degrees & certifications:

Ministry & Personal Information

If you have a sending church or agency, please provide the name or the church or agency, a contact name (first, last), address, phone number, and email. If you do not have one, please let us know and we can discuss opportunities for you:

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

Please share your testimony of how you came to faith and describe your current walk with God:*

Please share a brief history of your calling to the mission field including past ministry & cross-cultural experience:*

List your personal strengths and skills useful for this role:*

List your weaknesses:*

What are your hopes for this opportunity?*

Are you planning to be functioning in a full-time or part-time capacity? If part-time, will you need other sources of income to provide for yourself/family?*

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

Yes

No

You will receive an e-mail from Clear Investigative Advantage Research (CIAResearch) requesting permission for a mandatory background check.

If yes, please explain:*

Emergency Contact and Medical Information

I agree to have active medical insurance the entirety of my partnership with Healing Nations*

Healing Nations requires all missionary partners serving cross-culturally to maintain active insurance in case of emergency and need for medical care.

I Agree

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

Yes

No

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

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

Do you have any allergies?*

Yes

No

Please list allergies and allergy medications you take:*

Emergency Contact #1*

First Name Last Name

Relationship to you*

Phone*

Email*

Emergency Contact #2*

First Name Last Name

Relationship to you*

Phone*

Email*

References

Please list as many references as you can 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.

Pastor or Church Leader*

First Name Last Name

Pastor or Church Leader Email*

Length of Acquaintance

Current Employer*

Name of Supervisor/Manager*

First Name Last Name

Supervisor/Manager Email*

Spiritual Mentor or Ministry Co-worker*

First Name Last Name

Spiritual Mentor or Ministry Co-worker Email*

Length of Acquaintance

Friend/Peer Reference #1*

First Name Last Name

Friend/Peer Email #1*

Length of Acquaintance

Friend/Peer Reference #2

First Name Last Name

Friend/Peer Email #2

Length of Acquaintance

Ministry References

Please either share reference information for a previous ministry you have worked with or information for someone you have worked with in ministry previously.

Name of Ministry #1*

Ministry Reference Contact #1*

First Name Last Name

Ministry Reference Email #1*

Time spent working together:*

Description of relationship/partnership:*

Name of Ministry #2

Ministry Reference Contact #2

First Name Last Name

Ministry Reference Email #2

Time spent working together:

Description of relationship/partnership:

Name of Ministry #3

Ministry Reference Contact #3

First Name Last Name

Ministry Reference Email #3

Time spent working together:

Description of relationship/partnership:

Credentials

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, jpeg, Max. file size: 250 MB, Max. files: 2.

Please upload any credentials that are pertinent to the role you will be filling (medical licensure, etc.)

Drop files here or

Accepted file types: jpg, png, pdf, jpeg, Max. file size: 400 MB.

I agree to have active liability insurance (if applicable) during the entirety of my partnership with Healing Nations in order to practice medicine on the field*

Healing Nations will apply for this insurance on your behalf. The costs associated with the insurance can be built into your support raising goal.

I Agree

Waivers, Crisis Policy, and Code of Conduct

Please read through the entire document below and make sure that you understand and can agree to our Code of Conduct, Statement of Faith, & Crisis Policy.

I agree to at least a two-year commitment of serving in the field*

I agree

I agree to build my own financial and prayer team to support me while I serve in the field*

I agree

I agree to attend formal missionary training before being allowed to serve in the field with Healing Nations*

The costs associated with formal missionary training can be built into your support raising goal

I agree

I agree to pursue formal language training (if applicable) during the first few months of service to be proficient in speaking without a translator*

The costs associated with language training can be built into your support raising goal

I agree

I agree to meet all continuing education requirements outlined by my state's department of licensure to keep my license active and up to date*

The costs associated with continuing education can be built into your support raising goal

I agree

Signature*

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.