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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.
Country
*
Which country are you applying to travel to?
Approximate dates
*
What are the approximate dates for this trip (listed on PWH website)
Personal Information
Name as it appears on passport
*
First Name
Last Name
Middle Name
Suffix [example: MD, RN, RPT, etc]
Email
*
Email communication is critical for team planning. Please provide the best email address to reach you.
Verify Email
*
Phone
*
Address
*
Address Line 1
Address Line 2
City
City
State
State/Province
ZIP/Postal Code
Country
Passport Number
*
Expiration Date:
*
Passport Country
*
Indicate which country issued your passport (i.e. USA, Canada, etc.)
Do you speak more than one language?
If you speak more than one language, including American Sign Language, please indicate below
Yes
No
Language:
*
Fluency
*
Fluent
Minimal
Conversational
Read
Write
Employment
*
Full-time
Part-time
Student
Retired
Employment Information
Organization/Employer
*
Current position/ job title
*
Specialties (where applicable)
Former Employer
*
Former position/ job title
*
Specialties (where applicable)
University Information
University/ College Name
*
Major
*
Expected Graduation Date
*
Personal Health Status
Do you have any medical conditions or disabilities that could limit your activities and/ or prevent you from safely performing the volunteer services for which you are applying?
*
Yes
No
Please explain:
Do you have any dietary restrictions?
*
Yes
No
Please explain:
Do you have any known allergies?
*
Yes
No
Please list below
Do you have a problem with high altitudes?
*
Yes
No
I don't know
Please explain
Emergency Contact Information
Name
*
First Name
Last Name
Relationship:
*
Phone
*
Email
*
Verify Email
*
Address
*
Address Line 1
Address Line 2
City
City
State
State/Province
ZIP/Postal Code
Country
Medical Insurance Provider:
*
Insurance ID:
*
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 medicalmissions@partnersforworldhealth.org
Required Documents
The following materials are needed to complete this application.
A copy of the photo page in your passport.
*
This must be a clear scan or photograph.
Personal photo for ID badge, smile!
*
Copy of CV or Resume (BANGLADESH only):
Copy of diploma (medical personnel going to BANGLADESH only):
Copy of Board Certificate (physicians only)
Copy of current license (medical personnel only)
Credentialing Form (PROVIDERS to Bangladesh ONLY)
This form was sent via email; if not received, contact medicalmissions@partnersforworldhealth.org
Credentialing Form (REGISTERED NURSES to Bangladesh ONLY)
This form was sent via email; if not received, contact medicalmissions@partnersforworldhealth.org
