Cambodia International Outreach Application 2021

Name

Primary Phone

Have you taken The Heart Touch Method Training?

Email Address (our primary means of communicating with you):

Address

GENERAL INFORMATION

Gender:

Female Male

Date of Birth:

Social Security Number (required for international travel):

Passport Number:

City of Issue:

Issue Date:

Expiration Date:

Upload copy of valid passport (make sure not to expire within 6 months of travel date)
JPEG, JPG, PNG, OR PDF

Add files

Drop files anywhere to add

Language(s) spoken fluently:

List of countries outside the United States where you have traveled and the reason for your trip, e.g., business, vacation, volunteering, residence.

OUTREACH INTEREST

Country of Interest:

Cambodia Peru (in development-not yet scheduled)

How did you hear about the International Outreach Program?

What interests you about volunteering with the International Outreach Program?

What skills, talents, and interests do you have that could apply when participating in the Program?

If you have volunteered with any other organizations, please list their names and the services you performed.

If you have experienced any challenges while volunteering, please explain.

PROFESSIONAL AND EDUCATIONAL INFORMATION

Employer

Occupation

What are your long-range career objectives?

Educational History (degree and year):

If you are a healthcare practitioner, please indicate what type (e.g., massage therapist, nurse, chiropractor, physical therapist, acupuncturist, etc.).

Are you certified or licensed?

Yes No

If you are a massage therapist, do you have a city issued license or State of California certification?

Yes No

If a city license, provide name of city:

City License Number:

If State of California, indicate status:

State of California Certification Number:

List other bodywork certifications you have obtained.

Educational background/training:

Are you currently certified in CPR?

Yes No

VOLUNTEER HEALTH SCREENING

Have you ever been tested for TB?

Yes No

Results:

Do you have access to your immunization records?

Yes No

Briefly describe the condition of your current health condition.

If you have any special medical needs or allergies, please explain.

If you have any special dietary needs, please explain. We will make every effort to accommodate your needs.

REFERENCES

Reference #1

Name

Phone

Relationship:

Reference #2

Name

Phone

Relationship:

EMERGENCY CONTACTS

Emergency Contact #1

Name

Phone

Relationship:

Emergency Contact #2

Name

Phone

Relationship:

COMMITMENT TO PARTICIPATE

I am committed to participating in the International Outreach Program and I have cleared my schedule so that I may participate. I have saved the dates in my calendar. I understand that by completing this application, I am a candidate for the Heart Touch International Outreach Program but that this does not guarantee that I will be selected for the trip. If I am selected to participate I understand that I will need to pay a registration fee of $250. This fee will be used to hold my airline ticket. If I need to withdraw from participation if selected, I understand that my $250 registration fee will not be refunded.

Yes

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Date