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Canadian Mission Application Form

'*' - indicates a required field

Personal Information

Anticipated Departure Date	* (yyyy/mm/dd)
Anticipated Return Date	* (yyyy/mm/dd)
Full Name	* (as is appears on your passport)
Passport Number	We require a copy of the photo and information page of your passport.
Birth Date	* (yyyy/mm/dd)
Date of Baptism	(yyyy/mm/dd)
Age	*
Gender	*
Street Address	*
City	*
Province	*
Postal Code	*
Home Phone	*
Work Phone
Cell Phone
Email Address	*
Home Church
Occupation
	We require copies of any type of medical license you may have before you can be allowed to practice in Haiti.
T-shirt Size	*

Emergency Contact Info

Please supply the name and contact information of a trusted person whom we will notify on your behalf in the event of an emergency

Name	*
Relationship	*
Phone	*
Alternate Phone

General Health Information

What is your general state of health?	*
Do you have problems in any of the following areas?	Heart Blood Pressure Lungs Diabetes
Does your doctor require you to take any medication on a regular basis?	Yes No*
	If yes, please list the medication(s) and explain why you are taking them.
Please list any immunizations you have had recently
Please list any allergies

Questions

What is the main reason you wish to go to Haiti?	*
What is the main thing you wish to accomplish on this trip?	*
What are some of your skills and/or gifts you would like to use in Haiti?	*

Age of Majority Are you at least eighteen (18) years of age or older?
*Yes No

If No,
there are special considerations for anybody who is under the age of 18 to travel to Haiti. Please contact our mission office for more information regarding parental consent.

First Trip Will this be your first trip with Northwest Haiti Christian Mission, Canada?
* Yes No

If yes,
we require a written letter of recommendation from a minister and/or church leader from your congregation. The letter must be written on church letterhead, signed and returned by mail to our mailing address located in the Contect Us section of our website

Agreement to Terms and Conditions * I have read, understood and agree to the terms listed below

I do hereby certify that I am willing, physically fit and sufficiently prepared to travel with and participate in a work project with Northwest Haiti Christian Mission, Canada, in the country of Haiti. Trip sponsors have my permission to take me to a doctor for medical treatment, hospitalization, or emergency surgery if the need should arise. Should it be necessary for me to return home prematurely (due to medical reasons or disciplinary action), I will assume total responsibility for any additional costs incurred. I have read and agree to abide by the regulations/ guidelines and information included in the General Information Booklet.

By submitting this application you certify that you have answered all of the questions contained herein truthfully and to the best of your ability.

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