Preliminary Application Form Interested in going on a trip, but have not applied or been accepted yet? Please fill out this form. If you are human, leave this field blank. Your Full Name/ Nickname * First Name: (Exactly as it appears on your passport) * Middle Name: (Exactly as it appears on your passport) * Last Name: (Exactly as it appears on your passport) * Date of Birth * Address: * City: * State: * Zip/Postal Code: * Country: * Phone: * Email: * Current Employer or School: Current Occupation: -- select -- Physician Nurse Pharmacist Physical Therapist Other Specialty: Please describe your area of specialty Other occupation: Interested trips or travel date? Which HUFH trip are you interested in applying for, or, what month were you hoping to travel in? Previous volunteer or work abroad experience: Please describe any previous volunteer experiences and/or work in an international setting (please include length of time “in country”). Please describe your reasons for wanting to participate on a medical mission: How did you hear about HUFH? Hospital Brochure School Event News article Colleague Friend Relative Website Facebook Blog Other Please check all that apply. How I heard about HUFH: Human Check: Please enter the two words above, this helps us cut down on spam submissions.