Team Member Application Name* First Last Enter your name exactly as it appears on your passport, If you have to apply for a passport, type the name exactly as you will put it on your passport application. Airline tickets must be purchased with the exact name as it appears on your passport to be valid.Sex:MaleFemaleAddress* Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Country of CitizenshipPassport Number*Expiration Date* Mobile Phone NumberHome Phone NumberEmail AgeBirth Date Marital StatusIf married, spouses nameNumber of Children and Ages Health InformationHow would you describe your current health?ExcellentGoodFairPoorPlease list all allergies: Food:Environmental:Drugs:Other:Special dietary needs or food restrictions:HeightWeightBlood TypeMedications you are presently taking (include name/dose/frequency):Name of MedicationDoseFrequency To add more fields, click on the "+" icon on the right.Have you suffered a serious illness or recent injury, had major surgery or recently been hospitalized for any reason:YesNoIf yes, please explain:Are you pregnant?NoYesDo you have any physical restrictions or limitations?NoYesIf yes, please explain:Are you physically able to walk long distances?Are you physically able to tolerate 8-10 hour flights?Are you willing to obtain all necessary immunization and preventative medications? In case of an emergency, please contact the person listed below: NameRelationship to ApplicantHome Phone NumberCell Phone Number Nursing Experience RN LPN/LVN APN *Nursing License number(s):State: Specialties or Certifications:How long have you been a nurse?What areas of nursing do you have experience in?Has your nursing license ever been revoked?NoYesIf yes, explain:Have you ever been convicted of a felony?NoYesIf yes, explain:Are you willing to submit to a Criminal Background Check, if required?NoYes Ministry Information and ExperienceHave you been on any humanitarian or mission trips previously? No Yes If yes, please describe (where, when, duties).Describe any community service you have been involved in, if any: Miscellaneous InformationAre you willing to sign a liability waiver?Are you willing to participate in monthly conference calls for mission orientation?Do you speak any language other than English? If so, what language?Are you comfortable with attending a Christian worship service as part of the experience?If not, explain:What prompted you to inquire about a Nurses for Africa mission trip and what are you hoping to get out of the experience? Reference Checks:Please list the name and phone numbers of two references, one professional reference and one personal character reference (do not list relatives) Professional Reference:NameEmail Address:Home Phone NumberCell Phone Number Personal ReferenceName:Email Address:Home Phone NumberCell Phone Number Two t-shirts are included in your trip costs and will be mailed to you several months before the mission. Please select a size(s): Adult T-Shirt Size: Small Medium Large X Large XX Large * I acknowledge that the information I have provided to Nurses for Africa is accurate and true. Name*Date* This iframe contains the logic required to handle Ajax powered Gravity Forms.