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* 1. Please give us your contact information.

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* 2. Name of Pastor:

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* 3. Website:

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* 4. How long have you been a missionary or pastor at this location?

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* 5. Are you a part of a missions agency or denominational sending agency?

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* 6. If so, what is the name of the agency?

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* 7. How old is your church?

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* 8. Would you be hosting a clinic to grow your current church or plant a work in a new area?

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* 9. Will you be assisted by other churches and/or missionaries in your area? If so, please provide their names?

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* 10. How did you hear about Medical Missions Outreach?

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* 11. What time of year would be ideal for you to host a group?

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* 12. Please describe the healthcare system and availability in the area where you minister.

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* 13. Which of the following clinic areas do you envision as most beneficial for your area:

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* 14. Are you willing and able to provide 15-20 (based upon team size) translators for each of the four clinic days?

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* 15. Are your church volunteers (and possibly nearby churches of like faith) able to ensure that each patient will hear the gospel and be able to receive spiritual counseling and prayer?

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* 16. Are you prepared to assist our staff with planning a full itinerary, including budgeted in-country transportation, accommodations, meals, and recreational day activities?

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* 17. Is your ministry able to invest financially to advertise for the clinic in your community?

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* 18. Are you or a member of your staff able to help coordinate all paperwork that will result in the proper licensing and permissions for bringing medical supplies through customs?

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* 19. Does your community have a large school or community center that may be an ideal location for clinic (actual medical facilities rarely work for the patient volume we see)?

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* 20. Please attach a copy of your Doctrinal Statement.

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