Project MedSend Preliminary Application

All fields below require a response. 
Where you do not have a response appropriate please provide "not applicable".

Item Information
Your Full Name:
  Permanent Home Address
Address:
 
City:
State:
Postal Code:
Home Phone:
Email:
  Business Address
Address:
 
City:
State:
Postal Code:
Phone:
Email:
  Current Students
Please Complete the Following
School Name:
Current Address:
 
City:
State:
Postal Code:
Current Phone:
Current Email:
  Additional Information
Date of Birth:
Names and Ages of Dependents:
Profession (include degrees and certifications):
Current Status: In School (Year):
Resident:
Practicing:
Briefly relate how you became a Christian and your relationship with Jesus Christ. Explain how your faith influences the way you practice your healthcare profession.
Anticipated field of service:
Anticipated date of departure for the mission field:
Anticipated length of medical missions service:
Name of Mission Board:

Have you actually applied? Yes No

If no, when will you apply?

Have you had prior experience on the mission field (either long- or short-term)? Explain. 

 
Please comment on the the relationship that you see between the practice of your healthcare profession and evangelism/church planting on that field.
Anticipated total amount of student loans:
Interest rates, date payment begins:
What is the significance of your student loans as a barrier to reaching your field? Do you have an idea of the time it would take to pay them off without outside assistance?
Would you be willing to send a semiannual report to the organization or individual who would provide debt repayment for you while you serve?

Yes  No

I agree / do not agree to allow Project MedSend to use this information to solicit gifts and grants when donors ask for specific instances of need for debt repayment.

Please click the 'Submit Application' only once.  You will also receive a confirmation copy of your information to the email address you have provided.  Thank you!

       

Return to the Top of This Page.

 
Privacy Policy
Developed and managed by LongviewNET.

For problems or questions about our web site contact our , for all other inquiries contact .
Please read our web site License and Use Agreement.
Optimized for a screen resolution of 1024 x 768.