Mano con Mano
Mission Team Application
Name:__________________________________________Phone______________________
Address:________________________________________email:_______________________
City_______________________________________State__________________Zip________
Place of Employment___________________________________________________________
Address__________________________________________________phone:_____________
City________________________________________State_________________Zip________
JobTitle/Position:_____________________________Years of Experience:_________________
Age:__ _ Date of Birth:_______ _Place of Birth: _ _ _ _ _ _ _ __ Citizenship________________
Passport Number__________________
Emergency Contact:______________________________________Phone:________________
Address:______________________________________________Relationship_____________
City_____________________________________State:____________Zip:_______________
Health Insurance:________________________________Policy Number:__________________
Physician Name:_______________________________________Phone:__________________
Health Restrictions or conditions:__________________________________________________
Current Medications___________________________________________________________
Date of Last Tetanus Immunization:____________________(Required within 10 years before trip)
Hepatitis B Vaccine Series compelete?_____________(Required for all dental/medical/nursing staff)
Skills- Check any that apply and explain as necessary:
[ ] Dentist [ ] Dental Hygienist [ ] Dental Assistant [ ] Physician
[ ] Nurse [ ] Nurse Practitioner [ ] Physician’s Assistant
[ ] Food service [ ] Pastor [ ] Translator
Areas where you feel most suited to serve considering the specific needs of the current trip:______________________________________________________________
Personal Profile
Please take the time to answer the following questions, use additional paper as necessary.
1. Please share how you came to know Jesus Christ as your personal savior.
2. What is your Christian life like now?
3. Do you attend church regularly? Which one?
4. Why do you want to be part of this mission team?
5. Previous mission project experience? Describe:
6. Are there any roadblocks or doubts that might keep you from going? Explain:
7. Will you be able to attend 4-6 preparation sessions? (Preparation meetings are a necessary part of the work we do and considered mandatory unless emergencies arise. It is impossible to form a cohesive team without pre-field preparation.)
8. Do you agree to abide by the cultural, religious and behavioral expectations of the people we seek to serve even if it means giving up your personal freedom during the duration of the trip? (ie. modest dress, no smoking or alcohol)
9. What aspects of the trip do you look forward to the most?
10. What do you expect to be the most difficult/challenging?
11. Is there anything else that you feel team leadership should know about you?
12. Please list the name and phone number of two references who know you well?
It is my desire to serve as part of this mission team and I will set aside my personal rights to best serve the team, the project, and the Lord Jesus Christ.
Send to:
Mano con Mano Health Reach
1200 Bradner Pl South
Seattle, WA 98144