Total Health - Mission Trip Application

Mission Trip Application

Trip Location

Name

Date of Birth (mm/dd/yyyy):

/ /

Street Address:

Home Phone:

- -

City:

Work Phone:

- -

State:

Cell Phone:

- -

Zip:

Email:

Profession:

Trip Dates (mm/dd/yyyy):

From:

/ /

To:

/ /

US Citzen?

Yes No

If no, country of citizenship: Type "N/A" if you check Yes for US Citzen

Visa Status:

Passport Number:

Expiration Date (mm/dd/yyyy):

/ /

medical background/experience

Briefly describe your medical training and experience. Include areas of expertise and preferred
patient population.

references
Name:	Relationship:	Phone:
		- -
		- -
		- -

experience in overseas medical work
Past Trip Location:	Dates (mm/dd/yyyy):
	- -
	- -
	- -
	- -

Language skills
Language	Fluency
Language	Minimal	Limited	Fair	Good	Native

Personal medical information

Major Illnesses:

Regular Medications:

Allergies:

Treatments/Hospitalizations:

Physical Limitations/Restrictions:

Blood Type:
O +	O -	A +	A -	B +	B -	AB +	AB -

Vaccinations
Vaccine	Dates Given
Tetanus:	/ /
Typhoid:	/ /
Hepatitis A:	/ /
Hepatitis B:	1st / /	2nd / /	3rd / /

Unless your personal physician recommends otherwise, the basic immunizations we recommend are Hepatitis A, Hepatitis B, tetanus, typhoid, MMR (if needed), Varicella (if needed), and Malaria prophylaxis. Each traveler should check the CDC web site at www.cdc.gov for their latest recommendations. It is your responsibility to ensure that you are properly vaccinated.

I have read the above recommendations:

Signature:

Date Signed (mm/dd/yyyy): / /

insurance information
Current Insurance Company:	Policy Number:
Beneficiary For Travel Insurance Policy We Purchase For You:	Relationship:

Emergency contact
Name:	Contact Relation:
Street Address:	Email:
City:	Home Phone:	- -
State:	Work Phone:	- -
Zip:	Cell Phone:	- -

commitment
I certify that I have read the Total Health Travel Guide and understand the basic social differences and expectations in Latin America as described in the Travel Guide. I understand that I will be working with a local church and agree to work within to the social expectations of those I am working with. I certify that to the best of my knowledge the above information is accurate. I understand that it is my responsibility to obtain appropriate immunizations and I assume all risk associated with travel to Central America.
Signature:	Date Signed (mm/dd/yyyy): / /

By pressing “Submit” you agree that your typed signature is a valid signature.

Total Health welcomes donations designated for specific projects or purposes. We will make every effort to ensure that donations with these designations are used for the purposes expressed; however we reserve the right to use any donation for any purpose depending on the needs of the clinic. If a specified project is fully funded, or is no longer in effect, the funds will be used in the area of greatest need in the clinic. Donations that are made without a specific project or purpose designated will be use in the area of greatest need at the clinic.