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Ambassadors Medical Outreach and Relief Projects

Student Missionary Application

Use this application only if asked to do so by AMOR Projects administrators.

About You

Applicant Name * First Last
Address Line 1 *
Address Line 2
City *
State *
Zip *
Country *
Phone (preferred) *
Phone (other)
Email (preferred) *
Email (other)
Preferred Arrival Date *
Preferred Departure Date *
Preferred Service Activities *
MedicalDentalManual LaborTeachingEvangelismFarming

About Parent or Legal Guardian

Your parent or guardian will be contacted to provide updates from time to time
Parent or Guardian Name First Last
Address Line 1
Address Line 2
City
State
Zip
Country

Personal Information

Date of Birth *
Sex *
MaleFemale
Height *
Eye color *
Weight (lbs) *
Hair color *
Marital Status *
SingleMarried
How well so you speak Spanish? *
Not at allSomeFluently
What is your current dietary preference? Example: vegan, vegetarian, clean meats *

Your Church

What is your religious profession? *
Home Church
Pastors Name
Pastor’s Phone

Education

Education Status
Currently Enrolled at *
Year in School
Current Major
Graduated From *
Year
Majors / Minors

Passport

Name as it appears on your passport
Country of Issue
Passport Number
Expiration Date

Mission Experience

Please list past missionary experiences with the most recent first

Host Organization

From

Countries Visited

To

Duties

Host Organization

From

Countries Visited

To

Duties

Host Organization

From

Countries Visited

To

Duties

Emergency Contacts

Please list at least 2 emergency contacts

Name *

Relationship *

Phone (preferred) *

Phone (other)

Email (preferred) *

Email (other)

Name *

Relationship *

Phone (preferred) *

Phone (other)

Email (preferred) *

Email (other)

Medical History

Have you ever been diagnosed with any of the following conditions?
Asthma *
YesNo
Asthma explanation
Bleeding tendency *
YesNo
Bleeding tendency explanation
Depression *
YesNo
Depression explanation
Diabetes *
YesNo
Diabetes explanation
Epilepsy (seizures) *
YesNo
Epilepsy (seizures) explanation
High blood pressure *
YesNo
High blood pressure explanation
Migraine headaches *
YesNo
Migraine headaches explanation
Other conditions
Have you ever had any significant or serious illness/injuries? Explain. *
Have you ever had any operation or been advised by a physician to have an operation? Explain. *
Do you use any form of vision correction? Explain. *
Do you currently take any medications for control of a medical condition or do you require the use of a medical device? Explain. *
Please list all medications you currently take: *
List any allergies (food, environmental, or medication related) and type of reaction sustained: *
Have you ever been diagnosed with or exposed to tuberculosis? *
YesNo
Have you ever contracted malaria? *
YesNo

Required Vaccinations

Required vaccinations for any term of service include the following:

•MMR
•Polio
•Hepatitis A series
•Hepatitis B series (required for clinic workers, dental workers, and cook)
•Td (tetanus/diphtheria) within four (4) years of date of departure
•Typhoid
•Yellow fever

AMOR Projects recommends that all applicants obtain malaria prevention medication for duration of term (recommended mefloquine one tablet weekly or doxicycline one tablet daily). Please complete your personal vaccination information in the boxes below:

MMR

Dose #1 Date

Dose #2 Date

Dose #3 Date

Polio

Dose #1 Date

Dose #2 Date

Dose #3 Date

Hepatitis A

Dose #1 Date

Dose #2 Date

Hepatitis B

Dose #1 Date

Dose #2 Date

Dose #3 Date

Tdap diphtheria/pertussis/tetanus (DPT) Date
Typhoid Date
Yellow Fever Date
Chosen malaria prevention medication:

Getting to Know You

I am best described as a *
LeaderFollower
I work most effectively *
Under DirectionIndependently
Describe your character and personality in a short paragraph
Describe your motivation for service
Do you have brothers and sisters? List their names and ages
Describe your family life and what one thing you would change if you could
What do you do for fun and in your free time?
What volunteer or community service activities do you currently participate in?
Describe your current spiritual experience
How do you plan to maintain your spiritual experience while serving in Peru?
Why do you want to be a volunteer missionary?
What makes you interested in AMOR Projects’ ministry?
What skills or talents do you have that would add to this project?
How do you expect your term as a volunteer to affect you?
How do you expect your service will impact the people of Peru?
Describe where you see yourself in ten years

Verification

Please enter any two digits with no spaces (Example: 12) *
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