BRIEFLY RESPOND TO THE FOLLOWING QUESTIONS: (Note: These questions are not used as a basis for accepting or rejecting you. Rather, they are used merely as a tool to help you evaluate your readiness for departure to the field. All information is confidential... and it is optional. You may choose not to answer any questions contained on this form.)
Your name again please:
MEDICAL AND EMOTIONAL QUESTIONS Condition of Health: Excellent Good Fair
Any known allergies? (to medication or other):
Physical conditions -- Please indicate whether you have (or have had) any of the following: Asthma, Epilepsy, Leukemia, Cancer (type), Hepatitis (type), high blood pressure, Diabetes, Heart Problems, Stomach/Colon Problems, Back Problems, Migraines, Chronic Fatigue, AIDS Virus, Eating Disorders*, Learning Disabilities*, OCD (Obsessive/Compulsive)*, Depression*, Bipolar Disorder*, Substance Abuse*, Alcoholism*, ADHD (Attention Deficit)*, or other medical condition.
Have you had any traumatic experiences which have impacted your life? What impact would these experiences have on missionary service?
Have you been turned down for medical reasons from Life Insurance, Military, employment, college or other involvements? If so, would any of the above-mentioned conditions hinder missionary service? Please explain: If you indicated that you have (or have had) any condition above that had an asterisk, please answer the following 5 questions. If you did not indicate that you have (or have had) one of the asterisked conditions, you may skip to "Optional Questions" below.
1. What is the nature of the condition(s) you mentioned? 2. In what ways does your condition(s) limit your work or lifestyle?
3. Are you currently seeing a physician for your condition?
4. Are you currently or have you in the past taken any medication for this condition? If so, please explain.
5. Are you still struggling with any related issues? INFORMATION INTEGRATION: The following questions are designed to collect general information that we would typically ask once an individual is accepted. These questions do not form a basis for our accepting or rejecting you from Team Expansion. In fact, you don't even have to answer these questions. They are listed here merely as a "time saving" device for our office, thus allowing us to more quickly integrate your information into our database and thereby giving you a more smooth transition into Team Expansion.
Thank you for your willingness to share this information with us!
Do you have a valid passport? If so, please provide Passport Number
If you are not a U.S. citizen, please answer the following 3 questions: a) In what country is your citizenship? b) What type of visa do you have? c) What is the expiration date of that visa?
Full legal name of spouse (if any):
Name of child(ren) and date of birth of each
Clicking on "Submit" below is equivalent to signing this form. (Note: Don't click on "Reset" unless you want to clear this form and start over.)
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