Applicant Information Name *
As it appears on your passport.
Date of Birth * Month 1 2 3 4 5 6 7 8 9 10 11 12 Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 Highest degree or training at the time of the trip Home Address
* Email *
Phone * Country of Citizenship * Passport Number * File *
Please attach a high-resolution scan of the identification 2-page spread of your passport.
Accepted file types: jpg, png, pdf. What is your t-shirt size? * XS S M L XL 2XL 3XL Emergency Contact Information Name *
* Email *
Phone * Your Interest Destination * Somaliland: January 21 - February 1 Ethiopia: February 11 - March 15 Kenya: April 8 - May 10 Uganda: June 2019 Marinduque, Philippines: June 17-28 Santa Cruz, Philippines: July 22 - August 2 Mindoro, Philippines: August 19-30 Romblon, Philippines: September 30 - October 11 Why this trip? *
Describe why you are interested in participating in a M2H expedition. If you are a college student, please indicate your career
Your Education, Training, and Skills *
Please describe your education level, your occupation or profession, and any training or skills relevant to this trip (e.g., medical, construction, farming, mechanical, languages other than English). This information is often needed by M2H when applying for letters of invitation or permission to enter a host country to conduct a medical mission.
Your Experience *
Please describe any previous mission experience, any similar travel experiences, and/or any examples of living in under-resourced conditions (i.e., roughing it).
Your Health *
Please list any conditions or issues that may hinder your ability to serve as a member of one of our teams. Mission to Heal field teams often travel to remote and physically demanding environments. Your contributions to our efforts may include, but will not be limited to: lifting and carrying of supply bags weighing 50 lbs. or less, transportation of patients by stretcher, traveling long distance by automobile, forgoing a normalized meal schedule, and generally adapting to a resource poor and or high stress environment. Your safety is our obligation. An inability to perform the above tasks is not necessarily grounds for exclusion.
Additional Documentation Licenses
If you are a medical professional, please attach a copy of your appropriate licenses.
Accepted file types: jpg, pdf, png, jpeg. Resume / C.V. *
Please attach a resume or C.V. that details your experience and expertise.
Accepted file types: pdf, doc, docx. Volunteer Commitments
We are grateful to the dozens of volunteers who donate their time, talent, and energy to missions each year. As a nonprofit organization, Mission to Heal works in partnership with volunteers to ensure that the burden of cost is not transferred to the patients we serve.
Application Deposit *
To be considered for a M2H expedition, you must submit this application along with a deposit of $100 which counts towards your overall fundraising commitment.
If you are denied acceptance, or if you must withdraw from the proposed mission, the deposit will not be refunded. You may use the deposit in a later application for a trip; otherwise, we will both consider it a donation.
Fundraising $5,500 *
Joining a mission is free and all costs are covered by M2H, but all volunteers are required to fundraise $5,500 for Mission to Heal. This amount supports Mission to Heal in addition to covering the cost of airfare, food, lodging, transportation, medical supplies, and fuel for the Mobile Surgical Unit. Mission to Heal provides a fundraising toolkit and supports each volunteer in raising this amount.
Reflection Essay *
I acknowledge that a post-mission reflection essay is required of me and must be submitted within 2 weeks of the trip's completion. Failure to complete this reflection will result in receiving no credit for this mission, regardless of performance, and will be noted in any letter of recommendation on my behalf.
Media Release *
I grant Mission to Heal the right to use my photographs, video, and reflection essay as well as other photos and videos taken of me from this trip in print and digital form with or without my name for any lawful purpose, including publicity, advertising, and web content.
By signing this application, I, along with all members of my family, do hereby voluntarily waive any and all claims for any reason against Mission to Heal (DBA Mission2Heal), or its officers, leaders, and associated institutions or sponsors.
By signing this application, I also certify that to the best of my knowledge, I am physically and mentally able to participate in a Mission to Heal expedition.
Applicant's Digital Signature *
Guardian's Digital Signature
If applicant is a minor.