Date of This Application (d/m/yyyy):

*

Type of Application:

-Select One-Select OneNon-Medical VolunteerMedical ProfessionalTeam Leader*

First Name:

*

Last Name:

*

Phone:

() -

Cell Phone:

() -

Email:

*

Address:

*

Address (Line 2):

City:

*

ZIP Code:

*

State:

AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Other

Country:

United States Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua And Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos Islands Colombia Comoros Congo Cook Islands Costa Rica Cote D'Ivoire Croatia Cuba Cyprus Czech Republic Dem Rep of Congo Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Faroe Islands Fiji Finland France French Guiana French Polynesia Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Ivory Coast Jamaica Japan Jordan Kazakhstan Kenya Kerguelan Archipelago Kiribati Korea, North Korea, South Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Madagascar Malawi Malaysia Maldives Mali Malta Marshall Is Martinique Mauritania Mauritius Mauritius Is. Mayotte Mexico Micronesia Moldova Moldova CIS Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherland Antilles Netherlands Neutral Zone Nevis/Saintt Kitts New Caledonia New Hebrides New Zealand Nicaragua Niger Rep. Nigeria Niue Is Norfolk Island Northern Mariana Is Norway Okinawa(Japan) Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Island Poland Portugal Puerto Rico Qatar Reunion Is. Romania Russia Rwanda Ryukyu Is Saba Saipan Samoa American Samoa Western San Marino Sao Tome and Principe Saudi Arabia Senegal Rep. Seychelles Is. Sierra Leone Singapore Slovakia Slovenia Solomon Is. Somalia South Africa Southwest Africa/Namibia Spain Spitzbergen Sri Lanka Saint Christopher Saint Croix Saint Helena Saint Kitts/Nevis Saint Lucia Saint Maarten Saint Pierre/Miquelon Is. Saint Thomas (US V.I.) Saint Vincent/Grenadines Sudan Suriname Svalbard and Jan Mayen Is. Swaziland Sweden Switzerland Syria Tahiti Taiwan Tajikistan Tanzania Tatarstan Thailand Togo Tokelau Is Tonga Is Tortola Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Is Tuvalu Uganda Ukraine United Arab Emirates United Kingdom Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Is. - British Virgin Is. - US Wallis and Futuna Is. Western Sahara Western Samoa Yemen Arab Rep. Yemen Dem. Rep. Yugoslavia Zaire Zambia Zimbabwe Other *

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Marital Status:

-Select One-Select OneSingleMarriedDivorcedWidowed*

Birth Date (d/m/yyyy):

*

Birth Place:

Citizenship:

*

Passport Number and Expiration Date (d/m/yyyy):

*

Shirt/Scrub Size:

-Select One-Select oneSmallMediumLargeExtra Large*

Height and Weight:

Gender:

-Select One-Select OneFemaleMale*

EDUCATION

College(s) - Location - Dates:

*

Degree(s) - Date(s) - Major(s):

*

EMPLOYMENT

Contact Name (Salutation First Last):

*

Relationship:

Emergency Contact Home Phone:

Emergency Contact Cell Phone:

Emergency Contact Email:

HEALTH INFORMATION

List all current medical conditions:

List all current medications being used:

Describe any physical limitations that require accommodation:

List all allergies:

Name of Medical Insurance Carrier:

Insurance Group Number:

Insurance Policy Number:

RELATED EXPERIENCE AND SKILLS

Have you had any mission or cross-cultural experience?

-Select One-NoneOnceSeveralMany*

If so, please describe:

-Select One-NoYes*

If so, which language(s) and what is your fluency?

List your hobbies and talents that might be useful on our team:

PROJECT INTERESTS

What geographic areas of the world are your most interested in serving?

Which HHH project interests you most?

What would you like to accomplish in that project?

What most interests you about that project?

What months are you MOST available?

AllJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember

What months are you LEAST available?

JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember

What is your strongest personality trait?

What personality trait do you want to improve?

RELIGIOUS AFFILIATION

Have you read and agree with the HHH Statement of Faith?

Yes
No
*

Do you know Jesus as your savior?

Yes
No
Do Not Know
*

Briefly describe your testimony:

*

What best describes your Christian maturity?

-Select One-Select OneNot a believerSeeking Information about JesusNew BelieverLearning More About JesusMature Believer*

Explain:

Church affiliation:

-Select One-Not attending at this timeAttending occasionallyAttending regularlyMember*

Which church/denomination do you attend?

How long?

Church address, city, state:

Pastor name, phone, email:

MEDICAL PROFESSIONALS (skip if this does not apply)

What is your medical specialty(ies)?

Address of your medical practice:

Number of total years in practice:

Date of licensure (d/m/yyyy):