Truth for Today Medical Mission Application Form

Welcome to our online application form. Please tell us which mission you are applying for and the listed date of that mission.

Country Applied For *

Trip Date mm-dd-yy *

Name exactly as it appears on your passport. *

Enter your Passport Number if you have it, if not but you have applied for it enter 1. *

Passport Expiration Date. mm-dd-yyyy *

Nearest Major Airport *

Enter your name as  you wish to be called. *

Sex *

Age *

Date of birth. mm-dd-yyyy *

Address *

City *

State *

Zip Code *

Email *

Home Phone

Cell Phone *

Work Phone

My preferred contact phone number is *

Scrub Shirt Size *

Emergency Contact Name and Phone Number *

Church Name and Phone Number *

Occupation *

Do you have any degree, licensure, or certification in a medical area?  *

Please list any degrees, licenses, specialty training or certifications. *

Do you have any other special skills not included above which might be useful?  *

Do you speak any foreign languages? *

If you speak a foreign language, how well? *

Do you have any medical conditions which might affect your ability to perform in a rugged or tropical environment? If yes, please explain.  *

Do you have any food allergies or special dietary needs? Please be advised that we may not be able to accomodate all needs in a third world setting. Some dietary needs may require that you provide your own meals.  *

Have you ever been a part of a medical missions team? If yes, when, where and with whom? *

How did you find out about Truth for Today Medical Missions *

Have you ever been convicted of a felony? If yes, please explain. *

There will be restricitons of dress and habits designed to avoid an adverse testimony for TFTMM and our host ministries.  These include but are not limted to  a prohibition of alcohol, tobacco in all forms, e-cigs, foul or offensive language, and certain styles of dress (depending on the country).  Will you agree to abide by these conditions throughout the entire trip? *

I understand that by checking this box, I am electronically signing the trip application. Furthermore, I hereby affirm that I am the above named applicant and that to the best of my knowledge everything on this application is true and correct. *

I understand that by checking this box, I am acknowledging that I have read and am now electroncially signing the TFTBM  indemnification form.  *

$250.00 Non-refundable Application deposit. (Applies toward trip costs. I understand that this deposit is non-refundable.)  *

Medical professionals please send copies of your credentials to TFTBM  P.O. Box 91207  Chattanooga, TN. 37412

Please send a COLOR copy of your passport face page to: TFTBM  P.O. Box 91207  Chattanooga, TN. 37412.  *

I understand that medical evacuation insurance is required. I will provide my insurance policy number to tftbm no later than 2 weeks before trip departure. (If you do not have a personal medevac policy you may obtain one at www.sevencorners.com.) *

After submitting the application  you will be automatically directed to the donate page. If you have already paid, or intend to pay by check you may close the window.