Mission Trip Questionnaire
If you prefer to print and fill out a hard copy of the form, please email Esteban Cardona at Esteban.Cardona@scalpelatthecross.org to request a PDF version of the questionnaire. If you have any questions regarding the questionnaire please contact Esteban via email or phone at (305) 922-4486.
Email address *
First Name: *
Your answer
Last Name: *
Your answer
Home Address: *
Your answer
Home Phone:
Your answer
Mobile Phone:
Your answer
Date of Birth: *
MM
/
DD
/
YYYY
Marital Status: *
Do you have children? *
If you answered YES to the previous question please list their name(s) and age(s):
Your answer
How did you learn about Scalpel At The Cross? *
Your answer
Would your mission trip be self-funded or sponsored? *
Your answer
Please list your work history.
Your answer
Do you have knowledge of orthopaedics? *
Do you have knowledge of surgical equipment? *
Are you comfortable in a surgical setting? *
What talents do you feel you could bring to the team? Check all that apply. *
Required
What is your Spanish proficiency? *
None
Perfectly fluent in reading, writing, and speaking.
Would you be willing to be an interpreter? *
Have you been on a mission trip in the past? *
If you answered YES to the previous question, where did you travel and for how long?
Your answer
Please provide additional details about your mission trip (with which organization and your experience on that trip).
Your answer
Do you have any food allergies? *
If you answered YES to the previous question, please list ALL allergies.
Your answer
Do you have any special health considerations for your travel? *
If you answered YES to the previous question, please explain:
Your answer
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