As representatives of this Medical Mission Program, working with INTERNATIONAL CHILDREN'S MEDICAL FOUNDATION, (ICMF) and as a guest in a host country, participants are expected to abstain from using illegal drugs and publicly using alcohol and tobacco. They also should refrain from attending discos and bars for the duration of the ICMF Medical Mission Project. DOCTORS/NURSES INFORMATION pages must be read; with participants agreeing to adhere to same.

Please fill out and mail the form to the address indicated below with two passport size photos..


Name:_______________________________________ D.O.B.___________ M____ F____

Address:____________________________________________________

City: ___________________________

State: ________________ Zip:_________

Phone: _________________ Fax:________________

E-Mail:__________________________________


M..D. SPECIAL FIELD OF TRAINING: _________________________

RESIDENT - WHAT YEAR?_______________ FIELD:_____________________________

 NURSE - SPECIAL FIELD OF TRAINING:_______________________________________

TECHNICIAN - SPECIAL FIELD OF TRAINING:__________________________________

 OTHER - EXPLAIN: __________________________________________________________

Have you ever participated in any foreign medical mission trips before?________________________________

If so, with whom: ________________________________________________________________________

Trip(s) Duration(s): _______________________________________________________________________

WOULD YOU BE WILLING TO ASSIST IN GETTING ONE OF OUR MEDICALLY NEEDY CHILDREN HELP IN A HOSPITAL IN YOUR AREA? ____________________________________________________
IF SO, WOULD YOU BE LOOKING FOR ANY KIND OF "SPECIALTY" CASE? ____________________________________________________________________________

(1) Are you taking any medication on a daily or continuing basis?
Yes___ No____ If yes, please list_______________________________________________________________
___________________________________________________________________________

(2) Are you disabled, or limited in activity because of any present or previous illness?
Yes_____ No_____ If yes, please give details: ____________________________________________________________________________

____________________________________________________________________________

(3) Do you have dietary restrictions? Yes____ No_____
If yes, please use separate page and detail.

By answering these questions, you make the ICMF team leader's job easier if you, the participant, require assistance. (If additional space is needed, please use an additional sheet)

I, ________________________________________________________, in consideration of the benefits derived, if accepted for a Medical Group Mission project, hereby voluntarily waive any claim against the local and international organization, the Ministry of Health/Govt. of the host country, ICMF local officers, its sponsoring institutions and all leaders of INTERNATIONAL CHILDREN'S MEDICAL FOUNDATION for any and all causes in connection with the activities of the above organization. Waiver must be signed by every applicant.

SIGNED__________________________________________________ DATE___________________________

I understand that the participation fee covers all ICMF office operational expenses (which varies from project to project), and is payable to: INTERNATIONAL CHILDREN'S MEDICAL FOUNDATION . This fee must be in our U.S. office 60 DAYS BEFORE I LEAVE for the project.

I understand that a deposit of $200.00 (for nurses) and $300.00 (for doctors) must accompany my application, and my check, payable to: INTERNATIONAL CHILDREN'S MEDICAL FOUNDATION (PO Box 770795 - New Orleans, LA - 70117) is enclosed. I understand that this deposit is non-refundable but may, in the event of cancellation , with notice given, be transferred one time only to the next up-coming project.

I am applying for Medical Mission Project

Date(s):_______________________________________________________ (If currently unscheduled, write "open.")

SIGNED____________________________________________ DATE __________________

How did you hear about ICMF? ___________________________________________________________________________

Are you part of a group applying for this project? __________ If yes, which one?_____________________________

SPECIAL NOTE: Due to the effects that Hurricane Katrina has had on the U.S. mails in the New Orleans area we are asking that all Participants submit their deposits directly to us via PayPal.

Are you shopping for a special person in your life?

Be sure to visit our Fundraising Store: Agape Treasures

All proceeds from Agape Treasures purchases will be your *secure* direct deposit contribution

into ICMF's bank account.

If you are not shopping today and/or are unable to otherwise Participate, would you consider making a monetary donation? We value your gift, whether great or small, remembering and telling our children that someone “out there” cares about them. It’s people like YOU who make it possible for us to continue this great outreach. Know that you will be rewarded for your kindness!

Donate with any major credit card through PayPal! It's SECURE, FAST and FREE!