APPLICATION FOR MISSIONARY SERVICE PLEASE LIST ALL FAMILY MEMBERS AND AGES (IF YOU ARE SINGLE YOU MAY LEAVE THIS SECTION BLANK) Primary Applicant: DOB: Spouse: DOB: Child : DOB: Child: DOB:

Child : DOB: Child: DOB: Child : DOB: Child: DOB:

Application for service

Please save this document completed and email it back to the Christian Health Service Corps. All information in this document is confidential and will only be shared with appropriate CHSC personnel and potential receiving facility staff with authorization. Please type or neatly the print answers to the questions below. Please include a copy of your C/V with the application if you have been working as a healthcare professional in your home country. Copies of your professional licenses, board certifications and diplomas will be required. You may submit them with this application or after final board approval.

CONTACT INFORMATION Full Name (as it appears on your passport): Current address: City: State/Province: Postal Code: Permanent Address: City: State/Province: Postal Code: Home Phone: Cell Phone: Email: Health Profession: Specialty: Marital Status: Spouse’s/fiancées name: Anniversary date: If you have children, please give their names and date of birth:

EMERGENCY CONTACT INFORMATION Emergency Contact: Relationship: Home Phone: Cell Phone: Email: PASSPORT INFORMATION Passport #: Date Issued: Date Expires: Place of issue: Nationality: Date of Birth: Place of Birth: MISSION EXPERIENCE AND INTEREST Type of service you are applying for: Short-term (2wks – 12mos) Long-Term (>12mos.) Country or region where you desire to serve: If you are undecided do you desire our assistance with placement? Yes No Please list past mission experience: dates of service, organization and brief description: CHURCH AND CHRISTIAN COMMUNITY What main churches/fellowships have you attended since becoming a Christian? What is your current home church? Denomination: Are you a member of this church? Yes No If so for how many years? Pastor’s name, email and contact #: Mission leader/Pastor’s name email and contact #: Please relate how and when you became a Christian: Please share with specific examples how you are currently engaged in the missional life? In what activities or leadership roles have you served in your local church?

PHYSICAL AND EMOTIONAL HEALTH Do you consider yourself, your spouse, and/ or children if applicable in good health? Yes No If no, please explain use extra word document if needed.

Do you, your spouse, or children have any health or physical Yes No disabilities which make it hard for you or they to get around? If yes, please list. Have you, your spouse, or children ever suffered any serious illness Yes No or accident? If yes, please explain. Have you, your spouse, or children ever struggled with depression, Yes No anxiety or any other emotional or psychological illness? If yes, please explain. Yes No Are there any hereditary diseases in your family? If yes, please list. Name and contact of your primary care physician: Have you, your spouse or children ever had Have you, your spouse or children ever had problems with… problems with… If yes, please, use a separate sheet if needed If yes, please, use a separate sheet if needed YES NO YES NO Heart Heart attack/failure Circulation High blood pressure Arteries Irregular heart beat Lungs Pacemaker / internal defibrillator Breathing Asthma Brain High cholesterol Spine Diabetes Liver Cancer Kidneys Hernia Stomach Arthritis Muscles Hepatitis Thyroid Seizures Glands Stroke Numbness Concussion High cholesterol Diabetes Explanation: Explanation: EDUCATION (USE ADDITIONAL PAGES IF NECESSARY) Post Secondary Education /Residency/Fellowship Location: Degree: Location: Degree: Additional: Licenses and Certifications License: Expiration: Certifications: Expiration: Certifications: Expiration: Certifications: Expiration: Additional: Employment History Present Employment Name of Organization: Position: Dates Employed: May We Contact?: Duties: Previous Employer Name of Organization: Position: Dates Employed: May We Contact?: Duties: REFERENCES #1 REFERENCE Name: Relationship: Email: Phone #:

#2 REFERENCE Name: Title: Email: Phone #:

#3 REFERENCE Name: Name of Church: Email: Phone #:

Additional Information:

Will you need assistance with student debt? If so please complete the following: (If exact numbers are not known estimates are acceptable. When entering an estimated amount, please add (est.) suffix) Source of Debt Original Debt (if no debt from tuition or living expenses write: $0)

Totals:

Narrative Section

Please keep this section to 500 words or less. You will have the opportunity to expand on these areas in the interview process if you desire. You may include your answers here of add a separate word document.

Describe how you became a Christian answering the following questions:

Narrative Section Describe your motivation to be a missionary, including your sense of God's direction (in terms of length of service), biblical inspiration and people who have been influential in this process. Narrative Section Are you a member of a local congregation? (That is, a church where you are a member, which affirms your call to missions, acknowledges your call to the congregation, and provides ongoing emotional, financial, and spiritual support as well as accountability for your ministry).

Narrative Section How long attending: (if less than a year, list previous congregation) If you answered yes, please describe your service in that church. Include past experiences as appropriate.

Narrative Section Please comment on how your local congregation or “sending congregation” has already been or will be supporting you in the following areas:

a) Confirming your call to missions and acknowledging your call to the congregation:

b) Providing on-going emotional, financial and spiritual support:

c) Providing accountability for your ministry:

Narrative Section

Describe any short-term or long term mission experience

Narrative Section Are there any health conditions with you, your spouse, or children that require further explanation?

Spouse Narrative Section

Please keep this section to 500 words or less. You will have the opportunity to expand on these areas in the interview process if you desire. You may include your answers here of add a separate word document. Describe how you became a Christian answering the following questions:

Narrative Section Describe your motivation to be a missionary, including your sense of God's direction (in terms of length of service), biblical inspiration and people who have been influential in this process.

Narrative Section

Describe any short-term or long term mission experience

RELEASE I attest that all information provided in this application is true and that false or misleading entries will result in disqualification for service. Typing your full Name and Date of birth in the Applicant Signature Box will be used as your e-signature. Applicant Signature/DOB Date Signed RELEASE I attest that all information provided in this application is true and that false or misleading entries will result in disqualification for service. Typing your full Name and Date of birth in the Applicant Signature Box will be used as your e-signature.

Spouse Signature/DOB Date Signed