Project Compassion
11315 Rancho Bernardo Road, Suite 146
San Diego, CA 92127

 

Application for Medical Day Trip

Mission Trip Location:  MEXICO                Trip Date: 

Full Name:
Nickname for name badge:

Home Address:
City:
State: Zip:

Home Phone: Cell Phone: Work Phone:

E-mail address:

Date of Birth: Age: Gender:

Passport Number: Date of Issue:

Place of Employment:
Occupation:                

Do you speak other languages proficiently enough to serve as an interpreter?Yes

If YES, please specify:

Church regularly attending, if any:

Non-medical Personnel: I am interested to participate as a Helping Hand by assisting with:
RegistrationCrowd ControlPrayer/EvangelismTeaching Health EdTranslationAs Needed

 Medical Personnel:
 Type of License/Certificate:
 License Nbr:
 Years of Experience:
 Sterile Glove Size:

Contact to Notify in Case of Emergency

First Contact Name:
First Contact Relationship:
First Contact Telephone:

Second Contact Name:
Second Contact Relationship:
Second Contact Telephone:

Insurance Company:
Policy Number:

Do you have any physical limitations?Yes
Explanation (if yes):

Do you have a history of medical problems requiring ongoing treatment? Yes
Explanation (if yes):

Are you currently taking any medications? Yes List:

Do you have any allergies to food or medications? Yes List:

Name of Primary Physician:
Telephone Number of Primary Physician: