Home
About Us
Our Core Purposes
Our Guesthouse
Our Staff (No Names)
Our Needs
Contact Us
Home
About Us
Our Core Purposes
Our Guesthouse
Our Staff (No Names)
Our Needs
Contact Us
Name
*
First Name
Last Name
Date of Birth
*
MM
DD
YYYY
Age
*
Sex
*
Male
Female
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Preferred Phone
*
(###)
###
####
Email
Your Church Name and Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Passport #
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
*
First Name
Last Name
Emergency Phone
*
(###)
###
####
Emergency Email
MEDICAL PROFILE
My Health is
Excellent
Good
Fair
If Fair, please explain your condition:
Medications
List any MEDICATIONS you currently take
Allergies
List any medicines or substances to which you are ALLERGIC.
Limitations
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
(Must be within the last 10 years)
MM
DD
YYYY
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.
I Agree
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
General Office support
Computer technician & support
MEDICAL SUPPORT
Doctor (bring copy of license)
Physician’s assistant (bring copy of license)
Nurse practitioner/clinician (bring copy of license)
Nurse
Medical Assistant/CNA/EMT
Laboratory technician
X-ray technician
Pharmacist/pharmacy technician
Sonography technician
MAINTENANCE / CONSTRUCTION / PHYSICAL PLANT OPERATION
Concrete/masonry work
Carpentry
Plumbing
Electrical
Welding
Diesel or Machinery repair
General auto repair
Gardening/Landscaping
Painting
Additional Experience
Please list any other areas of experience or talents that you would like to share.
Special Needs
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.
Airline Carrier & Flight No.
ARRIVAL Date
MM
DD
YYYY
DEPARTURE Date
MM
DD
YYYY
Thank you!
