Application for Nigerian Medical Volunteers

Thank you for applying to serve on our medical project. PLEASE READ this complete document to familiarize yourself with our procedures. Please complete the entire form (multiple pages) by typing your information.

PEASE NOTE: Every volunteer is responsible for their transportation to the project site; IMO will provide accommodations and feeding for the duration of the project.

Project Date: March 24th-28th 2025
Project Site Address: Jos. Plateau State.

APPLICANT INFORMATION
2025 Medical Mission:

Application for Nigerian Medical Volunteers
Choose a project:*

Surgical Outreach - March 24th-28th 2025
STANDARDS OF CONDUCT AND BEHAVIOR
Our actions and behavior will profoundly impact people more than what we say to them. Be mindful of your behavior and model it upon that of Christ.
We do not want to be a stumbling block to others, nor do we wish to give offense and defeat our purpose by acting in a way that makes us look small or hypocritical.
We have a responsibility to lead by example to act as ambassadors.

We ask that you abstain from the use of alcohol, tobacco, and illegal drugs, from attending clubs and bars, and from any immoral behavior.
All participants in IMO short-term mission projects are expected to uphold these standards of conduct. The Team Leader is authorized to dismiss anyone who violates these standards of conduct and behavior immediately.
APPLICATION
Once you've been accepted, you will be notified by email, and you'll be expected to attend a MANDATORY ORIENTATION of policies and procedures and a one-hour CPR review of chest compressions, oral airway placement, and bag valve mask ventilation (for all anesthesia providers, surgeons, and doctors). PLEASE NOTE: No volunteer is paid to serve in IMO Mission projects.
Name:*

First NameMiddle NameSurname Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
E-mail*
example@example.com
Date of Birth*

DayMonthYear
Age:*
Sex?*

MaleFemale
Blood Type:
Marital Status:*
Religious Affiliation:
EMERGENCY CONTACT INFORMATION
Name*

First NameSurname Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Relationship?*

SpouseParentChildOther
MEDICAL PROFESSIONALS
REQUIREMENTS: All applicants and all Medical Professionals must provide the following.
• Copy of professional diplomas.
• Physicians:Board and Residency Diplomas, Current License/Certifications.
• Students/Residents: School ID.
• Nurses and Physician’s Assistants: Copy of current license
EDUCATION AND SKILLS: (List type of skill, degree, or specialty)*

DentalLaboratoryMDMid-wifeNurseOB/GYNOphthalmologistOptometristPedeatricPhysician AssistantPharmacistOther
OTHER INFORMATION
Upload a Copy of Professional Diplomas and Current License*

Cancelof
HELP US KNOW YOU BETTER:
Have you participated in an IMO medical mission project previously?*

YesNo
If yes, what year and what did you do?
What do you envision yourself doing on this project?
Did someone refer you to IMO? If yes, who?
INDEMNIFICATION AND HOLD HARMLESS
WHEREAS First Name* Last Name* (hereafter “team member”) desires to participate in the voluntary medical outreach mission in Nigeria from the dates of 24th to 28th March 2025, and WHEREAS, the team member desires to provide free will services to the needy population of Nigeria being served by International Mission Opportunities. NOW, THEREFORE, in consideration for the satisfaction of service, personal and/or spiritual growth, educational experience, and other good and valuable consideration, the receipt of which is hereby acknowledged: The team member hereby irrevocably and unconditionally agrees to release and hold harmless the International Mission Opportunities, its team leader, its Board of Directors, its Advisors and Consultants, employees and all others associated with the International Mission Opportunities, from any and all costs, expenses, liabilities, attorneyʼs fees, or any other damages, claims, or suits for damages, personal injury, wrongful death, or property loss/damage related in any way to the mission.

I do hereby acknowledge the inherent risk of international travel and the fact that injury, death, or disease might occur during or as a result of my service on an International Mission Opportunities project, and fully understand that the risks associated with such service may include, but are not limited to, injury or death by accident, loss of, personal property, lost, stolen, or damaged property; automobile, plane, mechanical, pedestrian, or any other accidents; medical illnesses; infections, including bacterial, fungal, parasitic, viral, HIV, etc.; post-traumatic stress, depression,
or mental anguish; uprisings within the country, imprisonment, difficulty entering
or leaving the country, a victim of deceit or fraud, death from natural or unnatural causes, or consequences of not providing adequate personal protection against the natural elements/conditions or diseases. I willingly assume these risks and waive any and all claims against the participating local and international organizations, the sponsoring institutions, their officers and employees, and the leaders of International Mission Opportunities,

I hereby acknowledge that I have read the "information package regarding the mission project and have had an opportunity to talk with the team leader and any advisors of my choosing about the risk inherent in the mission.

By signing below, I acknowledge that I have read, understand and accept all of the terms contained in this entire document.
Signature*

Powered by Jotform SignClear
Date*

MonthDayYear
Date
Should be Empty:

2025 Medical Mission:

STANDARDS OF CONDUCT AND BEHAVIOR

APPLICATION

EMERGENCY CONTACT INFORMATION

MEDICAL PROFESSIONALS

HELP US KNOW YOU BETTER:

INDEMNIFICATION AND HOLD HARMLESS