Preliminary Application Form

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:

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, and please tell us how you believe your skill set helps us accomplish our mission and deliver our programs.

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.