Host Application Survey

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* 1. Please give us your contact information.

Name

Host Church

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

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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:

Medical (general episodic clinic)

Optical (basic vision screening and fitting with eyeglasses)

Dental (primarily extractions)

Physical Therapy

Public Health Education

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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?

Yes

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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?

Yes

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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?

Yes

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

Yes

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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?

Yes

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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.

PDF, DOC, DOCX, JPG, JPEG file types only.

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