Last Name:

First Name:

Middle:

Street:

City:

State:

Home Phone:

Cell Phone:

Zip:

Work Phone:

Email:

Passport #:

Expiration Date:

US/Other:

Birth Date:

Occupation:

International Travel Experience:

Why are you interested in volunteering with Maisha Intl. Orphanage?

How did you learn about Maisha volunteer opportunities?

What is your current knowledge of the purpose of Maisha?

What additional information would you like to learn about Maisha?

Have you had a recent illness (in the last year?)

Explain:

When?

Do you have any allergies to food, drugs, insect bites or stings?

If yes, what?

Do you have chronic medical conditions?

Explain:

Do you take any medications?

Do you have any physical limitations or disabilities that would affect you in conditions such as extreme heat or cold, high elevation, limited food choices, etc?

Explain:

Have you ever been treated or hospitalized for a mental or emotional condition?

Explain:

Tetanus/Diphtheria Booster

Hepatitis A

Hepatitis B

Typhoid

Name:

Day Phone:

Relationship:

Evening Phone:

Address:

Insurance Company:

Policy & Group #:

Insurance Co. Phone#:

Physician's Name:

Physician's Phone:

Mission Project Country:

T-Shirt Size (unisex):

Is your deposit submitted? $100 Mexico, $250 overseas