Mending Hearts Abroad, Inc.

General Interest Form

Application Instructions

  1. Complete and sign the following application and release form
  2. Email the completed application to with the header ”Completed Mission application”
  3. Attach your resume in the email
  4. You will be added to a listserv of volunteers for all future mission trips

18536 Merseyside Loop

Land O Lakes FL, 34638

813-843-7484

Section 1: Personal Information

First Name: ______Middle: ______Last: ______

Gender: Male ❐ Female ❐ Date of Birth: ____/____/______

Home Address: ______City: ______

State: ______Postal Code: ______Country: ______

Home Phone: ______Cell Phone: ______Email: ______

Emergency Contact: ______Relationship: ______

Emergency Contact Primary Phone: ______

Foreign Language: Fluency:

Foreign Language: Fluency:

Foreign Language: Fluency:

Section 2: Education

Highest Education: Some High School ❐ High School Graduate ❐ Some College ❐

Associate's Degree ❐ Bachelor’s Degree ❐ Master’s Degree ❐ Doctorate ❐

High School Attended: ______

University/College Attended: ______

University/College Attended: ______

University/College Attended: ______

Section 3: Prior Experience

Have you previously traveled on any medical mission trips abroad? Yes ❐ No ❐

If so, what was the name of the organization? : ______

Year Traveled: ______Position Held: ______

Country Visited: ______

Section 4: Medical and Dental Professional Certification and Licensure

Medical Dental Allied Health Mental Health

Physician Dentist EMT/Paramedic Psychiatrist

MD ❐ DO ❐ DMD ❐ DDS ❐ MD ❐

Physician Assistant RDH Lab Technician Psychologist

Nurse Practitioner Dental Assistant Surgical Technician PHD ❐ PsyD ❐ MA ❐

Nurse Physical Therapist

RN ❐ CRNA ❐ LPN ❐ Dietitian/Nutritionist

Are you a current student in any of these fields? Which field? ______

Expected Graduation Date: ______/______/______

Do you have malpractice insurance? Next renewal date: ______

Certification/License Number: ______Expires: ______

Issuing Country, State/Province: ______

Section 5: Position of Interest

Please indicate which of the follows fields you would be interested in working in in the mission field.

Medical ❐ Dental ❐ Pharmacy ❐ Non Medical Volunteer ❐ Ministry ❐

Physician Intern/Shadowing ❐ Other: ______

Section 6: Questionnaire

  1. What attributes do you bring to the rest of the medical team that will be traveling with you?
  1. Describe a time in which you faced an adverse situation and explain how you resolved the problem?
  1. Please describe your greatest weakness?