APPLICATION FOR MISSIONARY SERVICE
PLEASE LIST ALL FAMILY MEMBERS AND AGES
(IF YOU ARE SINGLE YOU MAY LEAVE THIS SECTION BLANK)
Primary Applicant:
DOB:
Spouse:
DOB:
Child :
DOB:
Child:
DOB:
Child :
DOB:
Child:
DOB:
Child :
DOB:
Child:
DOB:
Attach personal or family Photo as a
separate file when you submit this
application. CHSC staff will add it to this
section for our files.
Application for service
Please save this document completed and email it back to the Christian Health Service
Corps. All information in this document is confidential and will only be shared with appropriate
CHSC personnel and potential receiving facility staff with authorization. Please type or neatly the
print answers to the questions below. Please include a copy of your C/V with the application if you
have been working as a healthcare professional in your home country. Copies of your professional
licenses, board certifications and diplomas will be required. You may submit them with this
application or after final board approval.
CONTACT INFORMATION
Full Name (as it appears on your passport) :
Current address:
City:
State/Province:
Postal Code:
State/Province:
Postal Code:
Permanent Address:
City:
Home Phone:
Cell Phone:
Email:
Health Profession:
Specialty:
Marital Status:
Spouse’s/fiancées name:
Anniversary date:
If you have children, please give their names and date of birth:
EMERGENCY CONTACT INFORMATION
Emergency Contact:
Home Phone:
Relationship:
Cell Phone:
Email:
PASSPORT INFORMATION
Passport #:
Date Issued:
Place of issue:
Date Expires:
Nationality:
Date of Birth:
Place of Birth:
MISSION EXPERIENCE AND INTEREST
Type of service you are applying for: Short -term (2wks – 12mos)
Long-Term (>12mos.)
Country or region where you desire to serve:
If you are undecided do you desire our assistance with placement? Yes
No
Please list past mission experience: dates of service, organization and brief description:
CHURCH AND CHRISTIAN COMMUNITY
What main churches/fellowships have you attended since becoming a Christian?
What is your current home church?
Are you a member of this church? Yes
Denomination:
No
If so for how many years?
Pastor’s name, email and contact #:
Mission leader/Pastor’s name email and contact #:
Please relate how and when you became a Christian:
Please share with specific examples how you are currently eng aged in the missional life?
In what activities or leadership roles have you served in your local church?
PHYSICAL AND EMOTIONAL HEALTH
Do you consider yourself, your spouse, and/ or children if applicable in good health? Yes
If no, please explain use extra word document if needed .
Do you, your spouse, or children have any health or physical
disabilities which make it hard for you or they to get around?
Yes
No
Have you, your spouse, or children ever suffered any serious illness
or accident?
Yes
No
Have you, your spouse, or children ever struggled with depression,
anxiety or any other emotional or psychological illness?
Yes
No
Yes
No
No
If yes, please list.
If yes, please explain.
If yes, please explain.
Are there any hereditary diseases in your family?
If yes, please list.
Name and contact of your primary care physician:
Have you, your spouse or children ever had
problems with…
Have you, your spouse or children ever had
problems with…
YES
YES
If yes, please, use a separate sheet if needed
NO
If yes, please, use a separate sheet if needed
NO
Heart
Heart attack/failure
Circulation
High blood pressure
Arteries
Irregular heart beat
Lungs
Pacemaker / internal defibrillator
Breathing
Asthma
Brain
High cholesterol
Spine
Diabetes
Liver
Cancer
Kidneys
Hernia
Stomach
Arthritis
Muscles
Hepatitis
Thyroid
Seizures
Glands
Stroke
Numbness
Concussion
High cholesterol
Diabetes
Explanation:
Explanation:
EDUCATION (USE ADDITIONAL PAGES IF NECESSARY)
Post Secondary Education /Residency/Fellowship
Location:
Degree:
Location:
Degree:
Additional:
Licenses and Certifications
License:
Expiration:
Certifications:
Expiration:
Certifications:
Expiration:
Certifications:
Expiration:
Additional:
Employment History
Present Employment
Name of Organization:
Dates Employed:
Position:
May We Contact?:
Duties:
Previous Employer
Name of Organization:
Position:
Dates Employed:
May We Contact?:
Duties:
REFERENCES
#1 REFERENCE
Name:
Relationship:
Email:
Phone #:
#2 REFERENCE
Name:
Title:
Email:
Phone #:
#3 REFERENCE
Name:
Email:
Additional Information:
Name of Church:
Phone #:
Will you need assistance with student debt? If so please complete the following:
(If exact numbers are not known estimates are acceptable. When entering an estimated amount, please add (est.) suffix)
Source of Debt
Original Debt (if no debt from
Amount Remaining
tuition or living expenses write: $0)
Totals:
Narrative Section
Please keep this section to 500 words or less. You will have the opportunity to expand
on these areas in the interview process if you desire. You may include your answers
here of add a separate word document.
Describe how you became a Christian answering the following questions:
Narrative Section
Describe your motivation to be a missionary, including your sense of God's direction (in
terms of length of service), biblical inspiration and people who have been influential in this
process.
Narrative Section
Are you a member of a local congregation? (That is, a church where you are a member,
which affirms your call to missions, acknowledges your call to the congregation, and
provides ongoing emotional, financial, and spiritual support as well as accountabili ty for
your ministry).
Narrative Section
How long attending: (if less than a year, list previous congregation) If you answered yes,
please describe your service in that church. Include past experiences as appropriate.
Narrative Section
Please comment on how your local congregation or “sending congregation” has already
been or will be supporting you in the following areas:
a) Confirming your call to missions and acknowledging your call to the congregation:
b) Providing on-going emotional, financial and spiritual support:
c) Providing accountability for your ministry:
Narrative Section
Describe any short-term or long term mission experience
Narrative Section
Are there any health conditions with you, your spouse, or children that require further
explanation?
Spouse Narrative Section
Please keep this section to 500 words or less. You will have the opportunity to expand
on these areas in the interview process if you desire. You may include your answers
here of add a separate word document.
Describe how you became a Christian answering the following questions:
Narrative Section
Describe your motivation to be a missionary, including your sense of God's direction (in
terms of length of service), biblical inspiration and people who have been influential in this
process.
Narrative Section
Describe any short-term or long term mission experience
RELEASE
I attest that all information provided in this application is true and that false or misleading entries
will result in disqualification for service. Typing your full Name and Date of birth in the Applicant
Signature Box will be used as your e-signature.
Applicant Signature/DOB
Date Signed
RELEASE
I attest that all information provided in this application is true and that false or misleading entries
will result in disqualification for service. Typing your full Name and Date of b irth in the Applicant
Signature Box will be used as your e-signature.
Spouse Signature/DOB
Date Signed