Medical Mission Application

Thank you for your interest in a medical mission with Refuge International! Please complete the form below and click Submit. Please also be sure to print and sign the waiver and consent form, along with copies of your medical license and passport, to Refuge International, 104 N. Montgomery, Gilmer, TX 75644.

Name (as it appears on passport)
Passport #
Date of Birth
Social Security #
Name you commonly go by
   
Address
City
State
Zip
Home Phone
Work Phone
Cell Phone
Email Address
   
Occupation
Employer
Employer's Address
City
State
Zip
   
Professional License Type and Number
Expiration Date
Medical/Nursing Specialty
   
Second Language
Fluency Level (Spoken)
Fluency Level (Written)
   
Third Language
Fluency Level (Spoken)
Fluency Level (Written)
   
Special Skills











Other
   
Felony Criminal Record (please explain)
   
Personal Reference (Name)
Relationship
Phone
   
T-Shirt Size (Unisex)
   
Medical Mission Trip Date and Destination
   
How did you hear about Refuge?
   
Have you been on medical mission trips before? If so, when and where?
   
I am also interested in being a Refuge volunteer in the following areas:


   
Medical Conditions
Current Medications
Allergies or Special Diet
Blood Type
   
Emergency Contact/Beneficiary
Relationship
Phone
Email Address
   
Health Insurance Company
Policy #
Insurance Company Phone

Image Verification

captcha
Please enter the text from the image:
[ Refresh Image ] [ What's This? ]