Name *
Name
Date of Birth *
Date of Birth
Address *
Address
Preferred Phone *
Preferred Phone
Your Church Name and Address
Your Church Name and Address
If you do not include your passport number here you will have to call us and provide it. We must have this for the insurance paperwork.
EMERGENCY CONTACT INFORMATION
Emergency Name *
Emergency Name
Emergency Phone *
Emergency Phone
MEDICAL PROFILE
List any MEDICATIONS you currently take
List any medicines or substances to which you are ALLERGIC.
List any physicial limitations you have.
Pregnant women, insulin dependent diabetics, people with serious chronic illnesses, or life threatening allergies are not eligible for travel to Haiti with HHM due to lack of emergency services in the country.
Tetanus Immunization
Tetanus Immunization
(Must be within the last 10 years)
AUTHORIZATION FOR TREATMENT
By checking "I Agree" below, I (or for and on behalf of my child under 18 years of age) give permission for an attending physician or hospital to administer medical treatments if deemed necessary by Haiti Health Ministries, and the physician or hospital staff during the project. I do for myself (or for and on behalf of my child under 18 years of age) hereby release from all claims and forever hold harmless the directors, employees, and agents of Haiti Health Ministries, from any and all claims and demands for personal injury, sickness, and death, as well as property damage and expenses, of any nature incurred by myself (or my child under 18 years of age). I also assume personal responsibility for all medical bills (for myself or my child under 18 years of age) and do certify I have secured primary medical insurance (for myself or my child under 18 years of age). Should it be necessary for me or my child to return home for any reason, I hereby assume responsibility for all transportation costs.
YOUR GIFTS ASSESSMENT
God has given everyone both physical and spiritual gifts that can be used to expand the Kingdom. Everyone can contribute. Please indicate the area(s) of service where you would like to lend support.
OFFICE & ADMINISTRATION
MEDICAL SUPPORT
MAINTENANCE / CONSTRUCTION / PHYSICAL PLANT OPERATION
Please list any other areas of experience or talents that you would like to share.
Do you have any special needs (diet restrictions, housing or room assignments, for example)?
FLIGHT INFORMATION
Do NOT book a flight arriving into Port au Prince later than 4:00 PM.
ARRIVAL Date
ARRIVAL Date
DEPARTURE Date
DEPARTURE Date