Weekender Application Note: this form is auto-saved as you fill it out. You can begin filling it out, leave the page, and come back later and your data will still be available. Please do not clear your browser cookies. General Registration Personal Name Name you prefer to be called (if different) T-shirt size: SmallMediumLargeXL2XL Address City State ---AL - ALABAMAAK - ALASKAAS - AMERICAN SAMOAAZ - ARIZONAAR - ARKANSASCA - CALIFORNIACO - COLORADOCT - CONNECTICUTDE - DELAWAREDC - DISTRICT OF COLUMBIAFM - FEDERATED STATES OF MICRONESIAFL - FLORIDAGA - GEORGIAGU - GUAMHI - HAWAIIID - IDAHOIL - ILLINOISIN - INDIANAIA - IOWAKS - KANSASKY - KENTUCKYLA - LOUISIANAME - MAINEMH - MARSHALL ISLANDSMD - MARYLANDMA - MASSACHUSETTSMI - MICHIGANMN - MINNESOTAMS - MISSISSIPPIMO - MISSOURIMT - MONTANANE - NEBRASKANV - NEVADANH - NEW HAMPSHIRENJ - NEW JERSEYNM - NEW MEXICONY - NEW YORKNC - NORTH CAROLINAND - NORTH DAKOTAMP - NORTHERN MARIANA ISLANDSOH - OHIOOK - OKLAHOMAOR - OREGONPW - PALAUPA - PENNSYLVANIAPR - PUERTO RICORI - RHODE ISLANDSC - SOUTH CAROLINASD - SOUTH DAKOTATN - TENNESSEETX - TEXASUT - UTAHVT - VERMONTVI - VIRGIN ISLANDSVA - VIRGINIAWA - WASHINGTONWV - WEST VIRGINIAWI - WISCONSINWY - WYOMINGAE - ARMED FORCES AFRICA/CANADA/EUROPE/MIDDLE EASTAA - ARMED FORCES AMERICA (EXCEPT CANADA)AP - ARMED FORCES PACIFIC Zip Email Preferred Phone Number Phone Type CellHomeWork Citizenship Date of Birth Gender MaleFemale Professional Profession Position Desired Present Education Level Missions & Professional Experience Date/Timeframe Available Language/Other How well do you speak Spanish? Click here for scale description. 012345 Can you do a medical history or physical exam in Spanish without a translator? YesNo Please list any special dietary needs How did you hear about Mexican Medical Ministries Why do you want to join this team? What would you like to do during your time in Mexico? (i.e. surgery, dental, evangelism, work with children, construction...please be specific) Spiritual Church you regularly attend Denomination Church mailing address Church phone Church fax Church email Name of pastor or point of contact at church If applicable, please briefly describe how you came to know Jesus Emergency Emergency contact name Relationship Phone List current health problems and physical limitations List medications you regularly require Yes, I affirm my qualifications as a candidate for the mission team with Mexican Medical Ministries. I agree to comply with the standards and directions of the missionary in charge during my participation on this mission team. I understand that any misinformation in regard to these requirements will constitute grounds for immediate dismissal from the program without financial refund. I have read the statement of faith of Mexican Medical Ministries. I agree to support the values and goals of Mexican Medical Ministries while serving with them. Signed (your name): on (date) Please download and print the Consent for Medical Treatment (PDF) and fill it out. Save the original and keep it with you at all times while traveling in Mexico. You may either email a copy to*protected email* or mail a copy to:Mexican Medical Ministries7850 Lester AveLemon Grove, CA 91945 ¿Puedes hablar español? Please answer the language question on the application form according to the guidelines provided below. This rating system uses a scale of 0 to 5 to denote a person’s level of proficiency in a particular language. With this rating scale you can more precisely evaluate where you are at in your language learning endeavor, and set goals for where you need to be. Level 0: The zero level is where we all start- no ability in the language. Once you have learned to use at least 50 words appropriately, you have graduated to the zero-plus level. Level 1: At level one, you are only able to express the most essential things to survive, like ordering a meal, asking directions to the bus station, basic greetings and leave-takings, etc. Level 2: By the time you reach level two you should be able to handle some limited work requirements, though your vocabulary is still quite limited and your accent is still quite noted. Level 3: Level three is when you have achieved a minimal professional level of proficiency in the language. You speak well enough that you can make close friendships, and you are adjusting pretty well to the culture. Level 4: A level four rating indicates full professional proficiency in your handling of the language. Level 5: And finally, level 5 is when you have reached the level of speaking like an educated native speaker- a tall order! There are levels in between each level to indicate you are well along towards the next highest level, but are not quite there yet. It is important that you be honest with yourself and evaluate what level you are at in your Spanish. If you are not at the level you need to be at, you need to do some serious thinking about how you can increase your proficiency to the necessary level. The better you learn the language (and the culture that goes along with it), the more satisfying your experience in Mexico will be. Mexican Medical, Inc. Statement of Faith WE BELIEVE in God the Father, an infinite, personal spirit, perfect in holiness, wisdom, power and love. WE BELIEVE that He concerns Himself in the affairs of men; that He hears and answers prayer, and that He saves from sin and death all who come to know Him through Jesus Christ. WE BELIEVE that the Bible is the Word of God, written under the inspiration of the Holy Spirit, infallible and without error in the original manuscripts and that it is the supreme authority in all matters of faith and conduct. WE BELIEVE Jesus Christ is God's only begotten Son, conceived by the Holy Spirit. WE BELIEVE in His virgin birth, sinless life, miracles and teachings. WE BELIEVE in His substitutionary atoning death, bodily resurrection, ascension into heaven, perpetual intercession for His people and personal visible return to earth. WE BELIEVE in the Holy Spirit, by whose regenerative work sinful man is born again and by whose indwelling regenerate man is enabled to live a godly life. WE BELIEVE that all have sinned and come short of the glory of God but that the triune God has provided for the forgiveness of our sins. We need only confess our sins, acknowledge Jesus Christ as Lord and Savior, and accept Him into our hearts and lives.