Med4Nicaragua Mission Trip 2012 Application

Please submit completed application to Connect the Docs by December 1, 2011.

First Name: *This question is required

Last Name: *This question is required

Address: *This question is required

City: *This question is required

State: *This question is required

Zip: *This question is required

Daytime Phone:

Evening Phone:

Cell Phone:

E-Mail Address:

Gender:

Male
Female

Marital Status:

Single
Married
Divorced
Widowed

Full name as it appears on passport:

Are you a U.S. citizen?

Yes
No

If no, which country?

Date of Birth: *This question is required

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Age:

Passport #:

Passport Country:

Passport Expiration:

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Occupation

Please describe your present employment and any pertinent information regarding work experience related to missions:

Language Fluency (Other than English)

	Language	Number of Years	Conversational Fluency (excellent, fair, poor)
1.
2.
3.

Skills and Talent
Please write the appropriate code next to the skills/talents you possess.
CODES: 1-Average 2-Above Average 3-Professional or Many Years experience

* Please note that not all of these areas may be offered on all trips.

MEDICAL
* Please attach a list of additional certifications

Physician
Nursing
Dental
EMT
CPR
Therapy (PT, OT, other)
Years Scrubbed
Years Circulated
Years Recovery/ICU
CNOR Certified

BUSINESS

Computers
Accounting
Marketing
Networking
Management
Operations

WEB

Design/Graphics
Writing

MINISTRY EXPERIENCE

Teaching Class
Children's Ministries

MUSIC

Vocal
Instrument

If you play an instrument, please specify which one(s):

OTHER SKILLS/TALENTS

Photography
Journalism
Juggling
Clowning
Construction
Carpentry
Painting
Masonry
Roofing
Electrical
Pluming
Puppetry
Drama

Please list any other skills or talents you have that are not listed above:

Mission Experience
Outline the previous mission trips you have taken

Trip Name
Date/Year
Impact

Copy of

Trip Name
Date/Year
Impact

Physical Limitations
We do our best to make mission trips as comfortable as possible. However, travel in general and short-term mission trips in specific may be extremely strenuous and stressful. Please detail anything in your current physical condition that may restrain you from activity:

Personal Assessment

Please rate each assessment from 1 to 10, 10 being strong, 1 being weak:

Relating to new people
Maintaining friendships
Sense of humor
Ability to finish what is started
Establishing relationships
Problem solving
Confrontation
Encouragement
Conversations with strangers
Listening
Ability to follow leadership
Being an example

What tends to upset you the most?

Describe your cross-cultural living, training and/or travel experiences. What did you learn? what types of difficulties did you experience?

Why do you want to participate in this project?

Electronic Signature:

Date:

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References

Please list three references (1 personal and 2 professional) that have known you for at least 5 years:

Name
Address
Phone
Email
Relationship

Copy of

Name
Address
Phone
Email
Relationship

Copy of Copy of

Name
Address
Phone
Email
Relationship