CRH June 2018 Mission Trip
INDIVIDUAL APPLICATION FORM
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) *
Your answer
Gender *
Date of Birth *
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Email Address *
Your answer
Mailing Address *
Your answer
Cell Phone Number
Your answer
T-Shirt Size *
Personal Health and History
If you answered "Yes" to any of the above questions, please explain.
Your answer
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
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
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
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
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
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
Interpersonal Skills: On a scale of 1-10, with 10 being the highest/strongest, please evaluate your personal strengths and weaknesses relating to humility
Interpersonal Skills: On a scale of 1-10, with 10 being the highest/strongest, please evaluate your personal strengths and weaknesses relating to confronting
Interpersonal Skills: On a scale of 1-10, with 10 being the highest/strongest, please evaluate your personal strengths and weaknesses relating to encouragement
Interpersonal Skills: On a scale of 1-10, with 10 being the highest/strongest, please evaluate your personal strengths and weaknesses relating to listening
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
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
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
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
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
Explain any of the above ratings that you feel need clarification
Your answer
Experience: Describe any prior mission trip experience you have had.
Your answer
Describe your medical experience, including field years of practice, and medical experience in a mission setting.
Your answer
Describe the skills you feel you will bring to CRH June 2018 Mission Trip
Your answer
Short Term Medical Professional Volunteer Coverage: Medical License Number
Your answer
Short Term Medical Professional Volunteer Coverage: License Country/State
Your answer
Short Term Medical Professional Volunteer Coverage: DEA Number (Optional)
Your answer
Short Term Medical Professional Volunteer Coverage: Nature of Practice
Your answer
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