Marion Medical Mission Application 2009
Checklist

Marion Medical Mission Application 2009

General Information:

        NOTE: Please list your name EXACTLY as it is shown on your passport.              
Last name __________________  First ____________________  Middle ____________ Birth date ________________

        Mailing address_______________________________________ City _____________ State ____________ Zip _______

        Male_____  Female_____ Email address___________________________

        Home phone________________ Work phone________________ Cell________________  Marital Status____________

        Passport number ____________________Expiration date __________ Place issued ____________________________

(If you do not have a valid passport, the process to get one could take several weeks)

        Are you a US citizen?________  If not, list citizenship _____________________________________________________

        Other than English, do you speak additional languages? __________________________________________________

PLEASE READ: Travel to Africa can be difficult, both physically and emotionally.  Please know that travel will be long and tiring; vehicles will primarily be 4-wheel drive trucks on very rough roads, paths and many times off road.  Well sites are reached by walking, often long distances, sometimes uphill.   During that time of year, weather will be hot - mid-80's to 100 degrees, sometimes very humid, often breezy with dust and wood smoke in the air.  Health care resources are often a long distance away and inadequate.  Please be sure you are in good physical shape for this trip.  For that reason you will be REQUIRED to carry health insurance that will cover a health related emergency while traveling abroad, including emergency air evacuation coverage.  If you do not have this type of coverage, we can recommend some low cost alternatives.

      Health Assessment: Do you have or have you ever had the following? 

•   High Blood Pressure __________  Stroke ___________  Heart Attack ________________

• Heart/Cardiovascular Surgery: ______   Type: ___________________________  Date: ________________

• Diabetes_________;  If yes, how is it controlled? ________________________________________________________________

• Seizures _________:  if yes, what type and how was it treated? ______________________________________________________

• Kidney Problems ____________________   Visual problems ____________________  Hearing problems ______________________

• Other serious medical problems ________________________________________________________________________________

• Surgeries in the past 6 months: ________________________________________________________________________________     

• Are you taking medications regularly? ______  If yes, please name them? ________________________________________________
  ________________________________________________________________________________________________________

• Do you have any drug allergies? _____________________________________________________________________________
  

• Do you have any other allergies?______________________________________________________________________________

        Health Risk/Habits and Lifestyle:

• Do you smoke? _______  How many per day? _____________

• Do you use alcohol? _____ How frequently?______________

• Do you use recreational drugs? _____  If yes, what and how frequently? _____________________

• Are you on any special diet? _______________________________________________________

• Do you exercise regularly? ______________________________________________________

        Please list your current health insurance company and policy number _________________________________________ 

        _____________________________________________________Does the policy cover you abroad?________________

        Does your insurance cover air evacuation in case of an emergency?_____If not, we can help you get coverage.  Do you want to apply for Group Travel Insurance?   ______

        Please provide two emergency contacts:

        Emergency contact name__________________________________Address____________________________________

        ___________________________________________________________ Telephone_____________________________

      Emergency contact name__________________________________Address____________________________________

        ___________________________________________________________ Telephone_____________________________

Experience:

        Current Employment Status: __________

        Describe any experiences that would equip you for MMM volunteer service. ___________________________________

        _________________________________________________________________________________________________

        _________________________________________________________________________________________________

        How have you served in your local church or community?__________________________________________________

        _________________________________________________________________________________________________

        ___________________________________________________________________________________________ ______

Brief Statement of Faith:

      ______________________________________________________________________________

      ______________________________________________________________________________

Areas of Interest:

        Available for service (circle all that apply):  Team 1 (Sep 18th - Oct 12th) Team 2 (Oct 9th - Nov 2nd)

        Have you traveled abroad or participated in any short-term mission trip before? _________________________________

        If yes, where? _____________________________________________________________________________________

        Have you ever participated on a Marion Medical Mission team? Yes ___No ___   If yes, when? ____________________

Service area preferences (check all that apply):  

§         ___ shallow well driving (Driving is generally off-road with manual transmission and opposite side steering)

§         ___  teacher or teacher training  (area of expertise ______________________________)                                        

        Other Skills that might be pertinent _____________________________                        

I understand that my talents and gifts will be used where the team leadership feels they are the most needed.

Previous volunteers have now completed their General Information form.  Please sign at the bottom of the next page.  First time volunteers need to complete the remainder of this form and sign at the bottom of the next page

References:

        Reference 1:

        Pastor  ________________________________________  Your Church ______________________________________

        Mailing address___________________________________________________ City ___________________________

        State ______________  Zip_______________ Email address______________________________________________

        Home phone ____________________  Work phone ______________________ Cell ____________________________

        Reference 2: (employer/supervisor is preferred if appropriate)

        Name _______________________________________  Connection to applicant ______________________________________

        Mailing address____________________________________________________ City ___________________________

        State ______________  Zip_______________ Email address______________________________________________

        Home phone ____________________  Work phone ______________________ Cell ____________________________

Describe how you came to know about the Marion Medical Mission:

        _________________________________________________________________________________________________

        __________________________________________________________________________ _______________________

        __________________________________________________________________________ _______________________

        _______________________________________________________________________________________ __________

___________________________________________________________________________________________________

_______________________________________________________________________________________________

____________________________________________________________________________________________________

______________________________________________________________________________________________

        Signature_______________________________________________________________ Date_____________________          _

There will be a personal interview with an experienced MMM volunteer

Marion Medical Mission 2009

Reference Form #1

Return to:

Marion Medical Mission
1412 Shawnee Drive
Marion, Illinois 62959

Applicant’s Name:  ________________________ has requested he/she be considered for a volunteer position with the Marion Medical Mission on a trip to Africa.  Your input helps us to assess their strengths for mission service in Africa.  Any information you provide will remain confidential.  Please answer the following questions based on your knowledge of the applicant using #10 as excellent, #5 as average and so on.  Mail your reference to the address shown at the top of this page.

1. How well is applicant able to adapt to new situations?                           1  2  3  4  5  6  7  8  9  10

2. How well does applicant demonstrate ability to be a team player?         1  2  3  4  5  6  7  8  9  10

3. How well does applicant accept direction and guidance?                        1  2  3  4  5  6  7  8  9  10

4. How well does applicant perform under stress?                                       1  2  3  4  5  6  7  8  9  10

5. How would you rate applicant’s overall cultural sensitivity?                  1  2  3  4  5  6  7  8  9  10

6. How much do you recommend applicant’s participation with MMM?   1  2  3  4  5  6  7  8  9  10      

7. Do you have additional comments about this applicant (use the back of this form if necessary)?

     ____________________________________________________________________________

____________________________________________________________________________

     ____________________________________________________________________________

     ____________________________________________________________________________

     ____________________________________________________________________________

     ____________________________________________________________________________

     ____________________________________________________________________________

Print Name: ____________________________________________________________________

Signed _____________________________________  Date ______________________________

Relationship to Applicant ________________________________________________________

Phone number ______________________  Email _____________________________________

Address _______________________________________________________________________

Marion Medical Mission 2009

Reference Form #2

Return to:

Marion Medical Mission
1412 Shawnee Drive
Marion, Illinois 62959

Applicant’s Name:  ________________________ has requested he/she be considered for a volunteer position with the Marion Medical Mission on a trip to Africa.  Your input helps us to assess their strengths for mission service in Africa.  Any information you provide will remain confidential.  Please answer the following questions based on your knowledge of the applicant using #10 as excellent, #5 as average and so on.  Mail your reference to the address shown at the top of this page.

1. How well is applicant able to adapt to new situations?                           1  2  3  4  5  6  7  8  9  10

2. How well does applicant demonstrate ability to be a team player?         1  2  3  4  5  6  7  8  9  10

3. How well does applicant accept direction and guidance?                        1  2  3  4  5  6  7  8  9  10

4. How well does applicant perform under stress?                                       1  2  3  4  5  6  7  8  9  10

5. How would you rate applicant’s overall cultural sensitivity?                  1  2  3  4  5  6  7  8  9  10

6. How much do you recommend applicant’s participation with MMM?   1  2  3  4  5  6  7  8  9  10      

7. Do you have additional comments about this applicant (use the back of this form if necessary)?

     ____________________________________________________________________________

____________________________________________________________________________

     ____________________________________________________________________________

     ____________________________________________________________________________

     ____________________________________________________________________________

     ____________________________________________________________________________

     ____________________________________________________________________________

Print Name: ____________________________________________________________________

Signed _____________________________________  Date ______________________________

Relationship to Applicant ________________________________________________________

Phone number ______________________  Email _____________________________________

Address _______________________________________________________________________

Marion Medical Mission 2009

Program Policies

Return to:

Marion Medical Mission
1412 Shawnee Drive
Marion, Illinois 62959

Financial Policies: 

Airfare has varied from $1,200 to $3,000 (and may be higher this year).  Room and board is estimated at an additional $400 to $700.  Volunteers should estimate a cost of up to $3000-$4000.  Your airfare is due prior to the date when airline tickets are reserved.  All travel expenses paid to Marion Medical Mission are tax deductible.

Program Policies:

Program volunteers must be at least 21 years old, hold a valid driver’s license and valid passport, have the required inoculations, and be covered by adequate insurance.  Shallow well team volunteers must be able to drive a four-wheel drive vehicle with a manual transmission.  Volunteers should have initiative and be able to work independently.

Cancellation and Refund Policy:

If an applicant cancels prior to the mission trip start date, the applicant will receive a full refund of air travel expenses paid less any fees imposed by the airline or travel agency.  Some airfares may not be refundable.  All cancellations must be received in writing.  The Marion Medical Mission reserves the right to cancel mission trips for any reason.  If for any reason the Marion Medical Mission cancels a mission trip, all applicants will receive a total refund of travel expenses paid to Marion Medical Mission less non-refundable items.

Additional Policies:

The Marion Medical Mission reserves the right to decline the application of or to ask anyone who is a danger to the mission, himself./herself or others, to leave the mission field.

MMM 2009 Teams will be selected by a selection committee after prayerful review of all applications.  Submittal of an application by either new or veteran volunteers does not guarantee acceptance to the team.  Selection will be made with consideration of the following:

• Team Composition: 40 to 50% new volunteers, 50 to 60% veterans

• Individual Volunteer's talents, skills, abilities and interest

• Compatible personalities

• MMM Project needs

• Health and Medical Concerns