EFM Medical Brigade Application
Thank you for showing interest in medical missions! We're happy you are applying. Unfortunately, since accommodations are limited, not all applicants will be chosen. Additionally due to the objectives of these trips, preference will be shown to qualified medical staff. Thank you for understanding. If you are not chosen for this trip, your application will be saved for reference on future trips.
Personal Information:
Name (as it appears on your passport)
*
First Name/First & Middle Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email Address
*
example@example.com
Passport Information:
Passport Number:
Passport Expiration Date:
-
Month
-
Day
Year
Date
Date of Birth:
*
-
Month
-
Day
Year
Date
Please attach a photo of your passport face page. This is the page that has your picture and passport number.
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Profession / Skills
Which trip date/dates would you be willing/able to join?
*
Spring
Fall
How do you hope to contribute if accepted for a medical brigade trip?
*
As a medical professional
As a Spanish translator
Other
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What is your medical degree?
*
If you currently work in the medical field, what type of work do you do?
*
Please upload a photo of your medical diploma or license renewal.
*
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Do you speak Spanish?
*
None
1
2
3
4
Fluently
5
1 is None, 5 is Fluently
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Are you currently enrolled in Bible college?
*
Yes
No
Do you feel called to work in foreign missions?
*
Yes
No
Do you speak Spanish?
*
None
1
2
3
4
Fluently
5
1 is None, 5 is Fluently
What medical professional will be accompanying you on the trip?
*
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Personal Health
Do you have any medical conditions that would limit your activity? If yes, please explain.
*
Do you have any dietary restrictions that would need to be accommodated? If yes, please explain.
*
Personal Reference
Pastor's Name
*
First Name
Last Name
Pastor's Phone Number
*
Please enter a valid phone number.
List the three best airports for you to depart from:
First
*
Second
*
Third
*
You will receive a commemorative shirt. Please choose your shirt size.
Please Select
XS
S
M
L
XL
2XL
3XL
4XL
Shirt Size Chart
Finalize
Please verify that you are human
*
Signature
*
Submit
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