Samaritan Medical Missions Application


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Step 1

Step 2

You must answer every question. If something doesn't pertain to you just insert N/A.

Name:
Address Line 1:
Address Line 2:
City:
State:
Zip Code:
Home Phone:
Mobile Phone:
FAX:
Email:
Passport Number:
Date of Issue and Date of Expiration:
Citizenship:
Emergency Contact:
Emergency Contact Phone Number:
Foreign Travel/Previous Mission Trips (List Countries):
Potential Dates Available:
Medical Background:
Specialty:
Are you available for Emergency relief trips?
Recent Vaccines: (List vaccine and date received)
Languages Spoken:
Health Limitations (Brief History):
Allergies - Food, medicines, insects, etc.:
Years in Practice:
Licenses/Certificates held and any restrictions:
Church Affiliation:
As a Christian organization, we encourage sharing the Gospel of Jesus. Are you willing to share?
Why are you interested in medical missions?
Terms & Conditions

Medical Treatment Consent:
I do hereby authorize Heaven Sent Ministries to seek medical treatment for me in the event that such treatment is deemed necessary and performed by a licensed Medical Doctor. These treatments include but are not limited to x-ray, medical or surgical diagnosis or treatment, or hospitalization.

It is understood that this authorization is given in advance of any specific diagnosis, treatment, or hospital care being required, but is given to provide authority and power to Heaven Sent Ministries to give specific consent to any and all such diagnosis, treatment or hospital care which the aforementioned physician inthe exercise of his/her judgment may deem advisable.

Release of Liability:
I shall indemnify, hold free and harmless, assume leability for and defend Heaven Sent Ministries, its agents, servants, employees, oficers and directors from anyand all liability from personal costs and expenses inclueding but not limited to, attorney's fees, reasonable and investigative costs, court costs, and all other sums for any claim or acation founded thereon, arising or alleged to have risen out of my use of the real or personal property belonging to or used by Heaven Sent Ministries while I am in the precence of Heaven Sent Ministries.

Payment Policy:
With the increasing number of people traveling under the umbrella of HSM on mission trips, we are implementing a payment policy to help reduce the burden to the minstry of paying for airline tickets for team members.

Airline tickets must be purchased well in advance of the trip by the ministry. It is important that each team member be prompt with payment. Payment schedules will be set up for each trip. You will be notified via email as to when each payment is due. Please make payments by the scheduled date to secure a place on the team.

Unfortunately, if your payment is not received when due, we will not be able to purchase your airline ticket. We will consider a late payment if the office is notified in advance.

Click "Continue" Button if you agree to these terms and conditions.

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Assisting the church in reaching the world for Christ.