CRH June 2018 Mission Trip
INDIVIDUAL APPLICATION FORM
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People from Different Religious Background Help the Poorest and Sickest in Rural Areas of Cameroon (Central Africa)
Please, select a mission trip of interest. *
Required
Name (Last, First, Middle, Nickname) *
Gender *
Date of Birth *
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Email Address *
Mailing Address *
Cell Phone Number
T-Shirt Size *
Personal Health and History
Clear selection
If you answered "Yes" to any of the above questions, please explain.
Interpersonal Skills: On a scale of 1-10, with 10 being the highest/strongest, please evaluate your personal strengths and weaknesses relating to people very different than you
Clear selection
Interpersonal Skills: On a scale of 1-10, with 10 being the highest/strongest, please evaluate your personal strengths and weaknesses relating to establishing friendships
Clear selection
Interpersonal Skills: On a scale of 1-10, with 10 being the highest/strongest, please evaluate your personal strengths and weaknesses relating to maintaining friendships
Clear selection
Interpersonal Skills: On a scale of 1-10, with 10 being the highest/strongest, please evaluate your personal strengths and weaknesses relating to sense of humor
Clear selection
Interpersonal Skills: On a scale of 1-10, with 10 being the highest/strongest, please evaluate your personal strengths and weaknesses relating to ability to finish what is started
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Interpersonal Skills: On a scale of 1-10, with 10 being the highest/strongest, please evaluate your personal strengths and weaknesses relating to problem solving
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Interpersonal Skills: On a scale of 1-10, with 10 being the highest/strongest, please evaluate your personal strengths and weaknesses relating to humility
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Interpersonal Skills: On a scale of 1-10, with 10 being the highest/strongest, please evaluate your personal strengths and weaknesses relating to confronting
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Interpersonal Skills: On a scale of 1-10, with 10 being the highest/strongest, please evaluate your personal strengths and weaknesses relating to encouragement
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Interpersonal Skills: On a scale of 1-10, with 10 being the highest/strongest, please evaluate your personal strengths and weaknesses relating to listening
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Interpersonal Skills: On a scale of 1-10, with 10 being the highest/strongest, please evaluate your personal strengths and weaknesses relating to conversing with strangers
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Interpersonal Skills: On a scale of 1-10, with 10 being the highest/strongest, please evaluate your personal strengths and weaknesses relating to ability to submit to/obey authority
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Interpersonal Skills: On a scale of 1-10, with 10 being the highest/strongest, please evaluate your personal strengths and weaknesses relating to being an example
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Interpersonal Skills: On a scale of 1-10, with 10 being the highest/strongest, please evaluate your personal strengths and weaknesses relating to acknowledge mistake/ask for forgiveness
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Interpersonal Skills: On a scale of 1-10, with 10 being the highest/strongest, please evaluate your personal strengths and weaknesses relating to flexibility with changes in schedules
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Explain any of the above ratings that you feel need clarification
Experience: Describe any prior mission trip experience you have had.
Describe your medical experience, including field years of practice, and medical experience in a mission setting.
Describe the skills you feel you will bring to CRH June 2018 Mission Trip
Short Term Medical Professional Volunteer Coverage: Medical License Number
Short Term Medical Professional Volunteer Coverage: License Country/State
Short Term Medical Professional Volunteer Coverage: DEA Number (Optional)
Short Term Medical Professional Volunteer Coverage: Nature of Practice
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