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Medical Mission Application

Medical Mission Application

Please complete all required sections of the application, below. Submitting this application is NOT equal to an acceptance for participation. PWH will be in contact after receiving your submission.

Which country are you applying to travel to?

What are the approximate dates for this trip (listed on PWH website)

Personal Information

Email communication is critical for team planning. Please provide the best email address to reach you.

Indicate which country issued your passport (i.e. USA, Canada, etc.)
If you speak more than one language, including American Sign Language, please indicate below

Employment Information

University Information

Personal Health Status

Emergency Contact Information


NOTE: if form will not let you submit as entered, type "00000000" in this field and email a copy of your health insurance card to

Required Documents

The following materials are needed to complete this application.

This must be a clear scan or photograph.

This form was sent via email; if not received, contact

This form was sent via email; if not received, contact