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Volunteer Application

Name as it appears on your Passport*

Date of Birth*

Passport Number*

Country of Issue*

Expiration Date*

Home Address*

Weight*

Personal Contact Number*

Work Contact Number

Your Email*

Name of Spouse

Emergency Contact*

Emergency Contact Number*

Relationship*

Do you have any physical limitation, illness or health issues?*

Yes

No

If yes, please describe

Have you ever been charged or convicted of a crime?*

Yes

No

If Yes, Please Explain

Are you currently Employed?*

Yes

No

Place of Employment

Job Title

Work Contact Number

Have you traveled with H.I.M.M. before?*

Yes

No

If yes, when and where did you travel?

Please list skills that you would be able to offer to the H.I.M.M. Team

Are you available to attend a mandatory team meeting prior to travel?*

Yes

No

If No, Please Explain

How did you hear about H.I.M.M.?

Comments or Concerns?

I have read H.I.M.M.’s Information and Guidelines for Mission Teams*

Yes

No

General Release - In consideration of Heal International Medical Missions arranging a volunteer assignment for me, I hereby release and forever discharge Heal International Medical Missionsor any board members from any and all claims that I may have, of whatsoever nature, relating to my time as a volunteer with Heal International Medical Missions. This includes, but is expressly not limited to death, bodily injury, personal injury, property damage, theft of property, economic loss or any other damage. I have read and agree with the above statement.*

Yes

No

Signature*

Date of Application*

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Volunteer Application

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