Departure Date: Month:
Day:
Year:
Trip
Cost Calculator
Return Date: Month:
Day:
Year:
|
• Please send a photo of yourself
(may email to info@hosptialsofhope.org)
• 5 deposit (This is transferable but not refundable.)
Put down your deposit online. |
Name as it appears on your passport
(if available)
First:
Middle:
Last:
|
Preferred Name: |
| First:
Middle:
Last:
|
|
|
Current Mailing Address:
Street:
City:
State:
Zip Code:
Country:
|
Home Phone:
Alternate Phone :
Email:
|
Permanent Mailing Address (if applicable)
Street:
City:
State:
Zip Code:
Country:
|
Citizenship:
Birthday: Month:
Day:
Year:
|
Passport Number (if available):
Place Issued:
Date Issued:
|
| Place of Employment:
|
Employer's Address:
Street:
City:
State:
Zip Code:
Country:
|
| Job Title:
|
| College/University You Currently Attend:
|
Undergrad:
Grad School/Seminary:
PhD:
|
| Major:
Minor:
|
| Anticipated Graduation Date:
Month:
Year: |
| Church You Currently Attend:
|
| Pastor’s Name:
|
Church Address:
Street:
City:
State:
Zip Code:
Country:
|
In Case of Emergency, I would like
Hospitals of Hope to notify:
Name:
Relationship:
|
Address:
Street:
City:
State:
Zip Code:
Country:
|
Daytime Phone Number:
Evening Phone:
|
| Email:
|
Health Status |
| Do you have any medical restrictions
or handicaps that we need to make provision for? |
|
(if yes please explain)
|
| Are you presently taking any medications? |
|
(if yes please explain)
|
| Do you have any dietary restrictions
that we should plan for? |
|
(if yes please explain)
|
| Health Insurance Company:
Policy
#
|
| Physician’s Name:
Phone
#
|
| Primary Area in Which You’d Like
to Serve (select one): |
|
| Other Areas in Which You’d Like
to Serve (select all that apply): |
|
| Medical/Dental applicants only: I am
currently (select all that apply): |
|
| Also please provide the following:info@hosptialsofhope.org
Undergrad
- Email Photocopies of all certificates and licenses to info@hosptialsofhope.org
- School you are attending & major of study
- Prior medical experience
- Personal goals or what you would like to accomplish while
in Bolivia
Grad students
- Same as above +year in school/level of training or study
Medical Professionals
- Email Photocopies of all certificates and licenses to info@hosptialsofhope.org
- Schools were you have received degrees
- Specialties
|
| Do you speak Spanish? |
|
| Are you proficient enough to be an interpreter? |
|
| Are you interested in helping in any
of the following areas (please select all that apply)? |
|
Leading a Devotion or Bible Study at the Guest House |
Acting in a Drama |
Leading Singing |
|
Leading Worship on Guitar |
...on Keyboard |
|
| Travel Information |
| Closest major airport: 1st choice:
|
| 2nd choice:
|
| Are the dates selected flexible? |
|
|
| If yes explain:
|
| What address should we mail the tickets
to? |
Street:
City:
State:
Zip Code:
Country:
|
| Please answer the following: |
| Short-answer questions (please answer
in 1-4 sentences) |
| 1. What is your primary reason for wanting
to serve overseas? |
|
| 2. Have you served on any overseas missions
projects before? If so, please list mission organization, date,
& purpose. |
|
| 3. In what ways do you believe you’ll
be able to impact people overseas? |
|
| 4. What do you hope to learn or gain
from this experience? |
|
|
| 5. Are there any realistic roadblocks
that might hinder you from going? |
|
| 6. What does the word “flexibility”
mean to you? |
|
| Long-answer questions (please answer
in approximately ½ a page) |
| 1. Describe your relationship with Jesus
Christ and how you became a Christian. |
|
| 2. What do you see as some of your strengths
and weaknesses? |
|
| Please provide a list of references including
name, address, phone #, and email address. |
- One Christian leader from your church (can be Pastor, Sunday
School Teacher, Bible Study Leader, etc)
|
|
- Two others who know you well. Cannot be a family member. We
would suggest a teacher, boss, coworker, fellow-student, or
friend.
|
|
| *Please note that we are not looking
for perfect volunteers. Please don’t let this application
be a hindrance to you in any way! |
| Hospitals of Hope is a 501(c)3 non-profit
organization. To obtain our receipt for tax purposes, make all checks
payable to Hospitals of Hope and please write a specific information
on a separate sheet of paper, NOT on the face of the check. All
funds raised above and beyond your targeted goal cannot be refunded
but will be used to further the ministry of Hospitals of Hope |
| WAIVER OF RESPONSIBILITY |
I,
along with all members of my family, in consideration of the benefits
derived if accepted for a Hospitals of Hope Project, hereby voluntarily
waive any claims for any reason against Hospitals of Hope International,
the officers, board, leaders, staff members and sponsoring institutions.
I,
will submit to the godly leadership of HOH staff.
I,
will have the full cost of my trip in to Hospitals of Hope by
the date departure. |
Signed
Date:
*Waiver must be signed by each applicant. Parent or Guardian
must also sign for minors. |
|
