Nonprofit Information

Christian Medical Fellowship 
504 Main Street
Farmington, CT  06032
Phone:  860-674-0698
Fax:  860-674-1364
Email:  cmf@c-m-f.org

 

 

 

Please visit our sponsors




 
 

 

 

 

Mission Application

Note:  Please do not hit the Enter key at any time while completing this application.  Please use your Tab key to move to the next question then select the "Submit" button (ONLY ONCE!) to send your application to us. Thank you!

Mission Trip Location:

Trip Dates:

Each Participant must fill out a separate form.
Full Name as appears on your passport (please complete each section for first, middle and last names) (Note: Ticket will be issued using this name - if not current, change fees may apply):

First Name:

Middle Name:

Last Name:

Name your prefer on your name badge:

Degree:

Are you a United States citizen or legal resident of the United States?

 Yes

 No

If not US Citizen, please give details:

Do you have a valid passport?

 Yes

 No

Your Passport Number:

Your Passport Expiration Date:

Mailing Address Line 1:

Mailing Address Line 2:

City:

State/Province:

Zip:

What address is this?

Home

Office

Home Phone:

Office Phone:

Office Fax:

Cell Phone:

Email Address:

Gender:

Male

Female

 Spouse's Name:

Birth Date (mm/dd/yyyy):

Church Affiliation:

Would you be willing to give a 5-10 minute devotional and/or lead praise/worship for the team? (voluntary)

Devotional?

Yes

No

Praise/Worship?

Yes

No

Have you attended any chapter meetings?

Yes

No

Are you Board Certified?

Yes

No

Eligible

What is your specialty?:

Are you a medical, dental or pharmacy student?

Yes

No

If yes, enter your current year (i.e. MS1, DS1, PH1, etc):

Expected graduation year?

Have you had any cross-cultural experience abroad?

Describe your experience:

Do your speak another language?
List languages other than English:    

What is your fluency level to speak the language?   

Have participated on a trip previously?

 Yes

 No

Please list any special skills you may have:

Scrub size? Please select your size by gender.

Men - Select size:

 None

 Small

 Medium

 Large

 XLarge

 XXLarge

Women - Select size:

 None

 Small

 Medium

 Large

 XLarge

 XXLarge

Emergency Contact (Name and relationship of person who will NOT accompany you on this trip):

Phone Number:

Complete Home Address (include country if not USA; enter SAME if address is the same as applicants):

We encourage all of our  participants to travel as a group via arrangements made by MTS Travel.  We understand there may be special circumstances where you might need to travel apart from the group.  You must get prior approval from the Trip Coordinator.

 
By checking Yes, I am agreeing to CMF's trip policies.

I have read the trip package and agree:

 Yes

 No

Dietary Restrictions? If yes, please describe:

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?

Are you physically fit for this trip?

 Yes

 No
Are you currently taking any medications on a regular basis?

Please list medications:

Known Allergies:

 

 

 

 

After submitting you will be referred to the CMF home page.  Thank you
 

 

Christian Medical Fellowship (CMF) is a nonprofit, nondenominational, Christian organization of individuals interested in the healthcare field.  We encourage spiritual growth through fellowship meetings, educational opportunities, and outreach projects.  We strive to join God's work in proclaiming His Kingdom through the provision of healthcare as outlined in Luke 9:2  Christian Medical Fellowship (CMF)  is a 501 (c) 3 non-profit charitable organization as defined by the IRS.

Last Updated 01/19/2008 11:00 EST

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