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Mission Application Form Guatemala





JUNE 20, 2019 MISSION APPLICATION FORM
GUATEMALA
To begin your application process, please fill out the following form.
When stating applicant’s name, please submit your name as it appears on the passport. One registrant per form, please.
NOTE: A $300.00 non-refundable/non-transferable registration fee is required to begin processing of your application. Application MUST be filled out completely to process and secure your spot on the team.

Dates of the trip: JUNE 20th – JUNE 25th, 2019

Full name as it would appear on passport:
Your Air Ticket will be secured in the name you have given us above – PLEASE make sure spelling is exactly as it appears on your passport or TSA will not allow you to board the plane. PLEASE PRINT CLEARLY
List name for name badge:
Date of Birth:

Social Security Number:
Mailing address:
Is this your home or office (please click one): HomeOffice
Home Phone:
Office Phone:
Cell Phone:
Office Fax:
Preferred Email:
Gender: MaleFemale
If married- Spouse’s Name:
Church Affiliation:
Have you had any cross-cultural experiences abroad? YesNo
If so, please describe:
If you speak any other languages than English, please list:
What is your ability to speak this language? TECHNICALCONVERSATIONAL
MISSION APPLICATION FORM – page two
If you have done other Missions Trips before, please list where
Is this your first trip with Heart2Heart?
YesNo
If NO – Please list the years you have served with Heart2Heart.
Area of Missions Interest: ConstructionEvangelismInterpreterMedical
Please list any special skills you could contribute:
Health Field: (please click one)
============================ MEDICAL PROFESSIONS ONLY ===============================
Specialties
Are you Board Certified?
YesNo
Eligible State License Number
Are you a Health Professions student?
checkbox* checkbox-802 id:HealthProfStudent “Yes” “No”]
Program type & Institution

=======================================================================================

Are you a U.S. citizen?
YesNo
If not, please give details:
Valid Passport Number
Date Issued
Expiration Date
Are you physically fit and free of medical conditions or disabilities that could limit your activities and/or prevent you (and others) from safely performing the volunteer services for which you are applying?
Physically Fit?
YesNo
Are you currently taking any medications on a regular basis? If yes, please list all medications
MISSION APPLICATION FORM – page three
Are you able to tolerate extreme heat and humidity? YesNo
Disclaimer: The Country of Guatemala is a tropical climate similar to South Florida. Therefore, participants on this trip may be exposed to periods of extreme heat, rain and humidity. If you have concerns about this, please check with your medical doctor to seek permission to participate on this trip.
Emergency Contact: Name
Relationship
Home Phone #
Cell #
Home Address
T-Shirt Size:
SmallMediumLargeXLargeXXLargeXXXLarge
Please include a $300.00 application fee with your completed application. Pay Application Fee Here
Confirm that you have TYPED your name clearly AS IT APPEARS ON YOUR PASSPORT.
Have you filled out this Application COMPLETELY?
By Typing Your Name, You are Signing This Form: The typed name below represents your signature:

Applicant’s Signature (Required for Processing)