Sample - APPLICATION FOR VOLUNTEER IN MISSION TEAM MEMBERS - Sample

VOLUNTEERS IN MISSION - HAITI PROJECT - From _____/_____/____ To _____/_____/_____

NAME:_____________________________________________________ Local Church Name:_________________________________

ADDRESS: _________________________________________________ Name of Pastor: ___________________________________

CITY: ______________________STATE: _____ZIP: ______ HOME TELEPHONE # _____- ____- _____ WORK# ____- ____-_____

DATE OF BIRTH: ____/____/____ BEST TIME TO CALL YOU: ______ AM OR PM

EMERGENCY CONTACT (SOMEONE WHO COULD BE REACHED- (IF NECESSARY) WHILE YOU ARE IN HAITI)

Name: ______________________________________ HOME TELEPHONE # _____- ____- ______ WORK# _____- _____-_______

Address:_____________________________________________________________________________________________________

YOUR PASSPORT #: _____________________ DATE YOUR PASSPORT EXPIRES: ____/____/____

MEDICAL INFORMATION

DO YOU HAVE MEDICAL INSURANCE? YES: ____ or NO: ____ If yes, please complete the following information:

INSURANCE COMPANY NAME: _________________________________________ POLICY #: _____________________________

MOST POLICIES HAVE SOME TYPE OF OUT OF COUNTRY RESTRICTION. DOES YOURS? NO: _____ YES: ____ IF SO, PLEASE LIST RESTRICTIONS: ____________________________________________________________________________________________________________ FAMILY PHYSICIAN'S NAME: __________________________________________________ PHONE #: _______-_______-________

ARE YOUR IMMUNIZATIONS COMPLETE? YES: _____ NO: _____ If no, when will they be completed? ____/____/____

HEALTH: ARE YOU TAKING ANY PRESCRIPTION MEDICATIONS? NO: ____ YES: ____ IF YES, WILL YOU AGREE TO HAVE AT LEAST A SUFFICIENT SUPPLY TO LAST YOU FOR YOUR TOTAL LENGTH OF STAY PLUS TWO (2) EXTRA DAYS? YES: ____ NO: _____

DO YOU HAVE ANY ALLERGIES? NO: ____ YES:____ If yes, Please list any allergies that you have: _________________________

DO YOU have "any" specific dietary restrictions? NO______ YES_____. If yes, please describe the restrictions:__________________

YOUR BLOOD TYPE: ____________________________________ Please note your health history and your current medical condition:

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

SKILLS: Check the skills that you may have. Circle the level of your performance. (G= GOOD, P= PROFESSIONAL. H= HOBBY, A= AROUND THE HOUSE) Speak Creole _____ G P H A Speak French ______ G P H A Masonry _____ G P H A

Carpentry _____ G P H A Electrical _____ G P H A Computer _____ G P H A Construction_____ G P H A

Travel _____ G P H A Homemaking _____ G P H A Arts & Crafts _____ G P H A Music _____ G P H A

MEDICINE: Do you have a current Professional Licence? No____ Yes ____ IF YES, What type of License do you have?________________________________________ IF YES, do you want to work in your field of experience? NO ____ Yes _____ IF YES, and you wish to use the skills that you have a license for, you "MUST" attach a copy of your License and a copy of your Diploma and return both of them to us "no later than" _____/____/____ It takes 3 full months to process your paperwork to work in Haiti.

GOALS: State briefly your reasons for going and what you expect to contribute and gain on this mission trip:______________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

ARE YOU WILLING to live and work under conditions that may be uncomfortable, and require flexibility and understanding? ________

ARE YOU WILLING to raise all the necessary funds for your travel and living expenses for this VIM Mission Trip?_________________

SELECTION OF ALL VIM TEAM MEMBERS WILL BE NOTIFIED BY MAIL.

______________________________________________________________ _____/_____/_____

Your Signature and Date

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