Preliminary Application For Prospective Volunteers

Applicant’s Name:_______________________________________________________

Address:_______________________________________________________________

Email address/phone:______________________________________________________

Date of birth:____________________________________________________________

1) What is your level of professional training/experience (e.g. 4th yr.medical student, 2nd year PA student, certified medical technologist, certified diesel mechanic, licensed/bonded master plumber, etc.):___________________________________________________________________

2) Other skills or significant experience (e.g. a) Construction/Maintenance, Skilled Painter, Welder, Experienced Carpenter b) Computer c) Secretarial d) Accounting/Administration, e) Teaching: _______________________________________________________________________

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3)  What is your time commitment (e.g. would like to stay one month, 6 weeks, etc.) and what range of dates are you available: ________________________________________________________________________

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 4) Please list any previous medium to long term mission experience (i.e. 3-12 months or more) & what you did on the trip:___________________________________________

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5) What is your Spanish Language proficiency (fluent, conversant, functional, survival, hola) and would you require a translator (at $10 per day) to perform your duties at Hospital Loma de Luz. However, this does not apply to 4th year medical students.________________________________________________________________

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6) If your spouse and/or children will be joining you, please list their professional & educational background and their level of involvement: ________________________________________________________________________

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7) Purpose of visit (i.e.Would you like to do this primarily for experience/educational credit, or from a calling to missions? Please explain): ________________________________________________________________________

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8) Who referred you to The Cornerstone Foundation / Hospital Loma de Luz?

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9) Please briefly share your faith testimony:___________________________________

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