Outreach Application | embraceandreach

Outreach Application & Health Form:

In Case Of Emergency Contact:

Emergency Contact Phone

Emergency Contact City / State:

Personal Data:

Passport Data:

QUESTIONNAIRE:

Education / Experience / Employment / Personal Information:

1.Have you ever traveled overseas? Where, when, and for how long?

2. What is your educational background? Are currently enrolled in school? Where do you work/present occupation? Will there be any difficulty getting time off for this trip?

3. Why do you want to minister on this short term outreach trip?

4. Serving God in a foreign environment requires that we live outside of our own cultural norms. Will you be able to lay aside personal expectations/standards regarding personal conveniences, food, sleeping, time orientation and accommodations, etc…? Are you willing to submit to the leadership of this team and the training process/mandatory training of this Outreach team?

5. What are your goals for personal growth over the next 6 months? During this outreach?

Spiritual Background:

Briefly state the date and circumstances of the following in your life:

1.Describe your personal experience in committing your life to Christ?

2. Describe your personal daily walk with Jesus since you put your faith in Him? Are you presently in a small personal growth group /small group at your local faith community or meeting with someone who is personally encouraging you in your walk with the Lord?

3. What faith community (church) do you presently attend and how long have you been attending? In what capacity are you currently serving at your local faith community?

4. What previous training in local/foreign outreach and ministry have you had?

Skills / Talents / Experience Inventory:

Please rate the degree of your skill/comfort level in the following areas as follows:

1 = Experienced; 2 = Interest With Some Experience; 3 = Interested But No Experience; 4 = No Interest / No Experience

Communications / Leadership:

Music / Performing Arts:

Medial / Dental:

Nurse (specify type please)?

Physician (please specify specialty and please upload a copy of your license and DEA number below, in order to practice overseas)

Physicians please upload a copy of your license and DEA number is order to practice overseas

Upload File

Other Skillsets:

Sports:

Health Questionnaire:

1.When was your last physical exam? What is your appraisal of your present health condition?

2. Have you ever been treated for any major physical illness/injury? Hospitalizations? Please specify.

3. Do you have any chronic/recurring health problems? Do you have any condition that may hinder you from participating fully in this outreach. If so , please specify.

4. Do you have any allergies/adverse reactions to food/medications/substances?

5. Do you have any of the following? Asthma, Diabetes, Heart Disease, Stomach/Ulcerative Conditions, Hearing/Vision loss, Musculoskeletal Conditions? Please specify.

6. Are you currently under-going any medical treatment/taking any prescription medications? Will you be taking your medications on this trip? Please specify.

7. Have you ever suffered from or received treatment for emotional/mental illness? If so, please specify.

8. In case of any medical emergency away from home whom do we contact that would be knowledgeable about your health?

In case of an emergency, I hereby authorize any necessary medical treatment by proper medical personnel in the country that I am visiting.

Please Type / Sign Full Name

Please Type "I Agree"

Today's Date:

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