MEI Registration

Mission trip location:

First name as it appears on passport:

Middle name as it appears on passport:

Last name as it appears on passport:

For insurance coverage, please enter scheduled date of departure from the US (mm/dd/yyyy):

For insurance coverage, please enter scheduled return date that you will arrive in the US (mm/dd/yyyy):

Date of Birth (mm/dd/yyyy):

Specialties:

In preparation for the trip, MEI will need to communicate with you. What email address do you prefer that we use?

What phone number do you prefer?

Are you a United States citizen or legal resident of the United States?
YesNo

Do you have a valid passport?
YesNo

Nationality of passport:

Passport number:

Passport expiration date (mm/dd/yyyy):

Are you willing to give a 5-10 minute devotional for the team?
YesNo

Are you willing to lead praise/worship for the team?
YesNo

Name and relationship of emergency contact person (who will not accompany you on trip):

Phone number of emergency contact person:

Complete home address of contact person (include country if not USA; enter same if address is the same as applicants):

Do you have dietary restrictions?
YesNo

If yes, please describe:

Are you physically fit and free of medical conditions or disabilities that could limit your activities and/or prevent you from safely performing the volunteer services for which you are applying?
YesNo

List all medications you take on a regular basis:

Do you have any known allergies?
YesNo

If yes, please describe:

Do you have an advanced directive or power of attorney for health care?
YesNo

If yes, give details of designated decision maker and healthcare preferences/restrictions:

I agree to reimburse the cost of non-refundable airline tickets or other arrangements paid for by MEI and/or the in-country host if they are not used because of a change in my plans.
I Agree

I hereby acknowledge the inherent risk of international travel and the fact that injury, death, disease, might occur during or as a result of my voluntary service on any CMDA/MEI project, and fully understand that the risks associated with such service may include, but are not limited to, injury or death by accident, disease, terrorist acts, adverse weather conditions and inadequate medical care, and/or damage to, or loss of, personal property. I, in consideration of the benefits derived from being accepted for service, hereby volunteer my services despite such hazards.

I willingly assume these risks and I hereby waive any and all claims against the participating local and international organizations as well as the sponsoring institutions, their officers and employees, and the leaders of the Christian Medical/Dental Associations, for any and all causes in connection with the activities of the above organizations and individuals on the Project.

I understand the policies and procedures stated herein on the supplemental statement of Expectations for Exemplary Personal Conduct and I agree to abide by them. I understand that misrepresentations in my application or breaching Biblical standards of conduct will be grounds for dismissal from that project.

I understand that MEI may publish photos and testimonies of participants on this mission, including myself as a participant, uplifting the service in which this project was intended.

CMDA requires participants to use CMDA's travel insurance regardless of what other insurance a person has.

MEI policy is that reimbursements hosts provide in excess of team member’s costs will remain with MEI.

By submitting this form, I affirm my complete agreement with the above CMDA terms and waivers.