IDM Service Application

(For individuals desiring to serve on short-term dental mission trips)

Applicant's FULL LEGAL NAME: (No nicknames; list your full legal name)

Please submit your application to IDM by clicking the 'Submit' button below. The Board of IDM will then make a decision regarding your desire to work with IDM on a future trip.

International Dental Ministries, Inc.
7900 E. Greenlake Dr. N. Suite 300
Seattle, WA 98103 USA
Phone: (206) 859-2767
Fax: (206) 859-2768
Email: idmserve@gmail.com
www.idmserve.org

Instructions: The completion of this form will enable International Dental Ministries (IDM) to consider you for short-term ministry in a Christian mission setting. Please answer all applicable information. All information will be confidential and will only be shared with appropriate personnel. Use separate sheets if necessary.

General Information

FULL LEGAL NAME AS ON YOUR PASSPORT

Name:

M F

Address:

City:

State:

Zipcode:

Email:

Phone Number:

Passport #:

Passport Expiration Date:

Birth Date:

Foreign Languages Spoken:

Fluent Conversational Minimal

Church/Religious Affiliation:

T-Shirt Size:

Small Medium Large X-Large

Education & Employment

Highest Education:

High School College Post-Graduate

List Degrees:

(If applicable) Dental or Medical License # :

State:

Expiration Date:

Occupation:

Number of Years:

Mission Interest

How did you hear about IDM?

Internet Newsletter Email

Other:

Trip Volunteering For:

Dates Available:

Have you traveled overseas previously?

Yes No

Where?

Please provide a short summary of why and in what capacity you desire to work with IDM.

Medical Information

Please complete the following medical information form in its entirety to the best of your knowledge.

Blood Type:

YES	NO	CONDITION
		Heart Issues (Attack, Chest Pain, Angina) Date of Last Episode:
		Respiratory Issues (Asthma, History of Altitude Sickness) Date of Last Episode:
		Allergies (Foods, Animals, Pollens, Latex) Specify Allergy:
		Diabetes (Type I or Type II)
		Seizure Disorder Date of Last Episode:
		Tuberculosis
		Pregnant or Possibly Pregnant
		MEDICATIONS
		Blood Thinners
		Blood Pressure Medications
		Insulin/Diabetes Medication(s)
		Antidepressants
		Inhalers
		Nitroglycerine
		Any other medication not listed above

Physician's Name:

Physician's Phone:

***Are you being treated for a Chronic Illness/Injury? ***

Yes No

If yes, a Physician Statement to travel and participate on a Short Term Mission Trip is required and should include diagnoses and treatment. A form is attached for you to take to your physician (appendix 1). Please returned the signed statement no later than six weeks prior to travel date.

LIST ALL MEDICATIONS TAKEN: (dosage and time of administration below)

Name of Medication	Dosage	Time of Administration

Please note that the standard of medical practice is not the same as in the USA, bring an extra week of all prescribed medications.

Are you able to skip an occasional meal?

Yes No

Do you have any health problems or physical limitations that might hinder your work in a different climate, high altitude or adverse living conditions?

Yes No

Emergency Contact

Name:

Address:

City:

State:

Zipcode:

Email Address:

Phone Number:

Immunizations

Vaccines necessary for travel are: Hepatitis A, Hepatitis B, Typhoid, MMR and Tetanus

Date:

Immunization:

Statement of Practice and Faith

I realize that the following elements are crucial to the effectiveness, quality, and safety of our trip together. As a member of the mission’s team, I agree to:
1. Remember that I am a guest working at the invitation of International Dental Ministries and the local host. I am willing to set aside personal preference, habits and schedule in the interest of others to fulfill the mission of IDM and to share the love of Christ with the world.
2. I understand that there are variations in practice and understanding of Scripture in some areas of doctrine, Christian living and witness. In serving with IDM, I will abide by standards as to not offend those we are serving. This includes a willing agreement to abstain from the use of alcohol, drugs, and tobacco and being sensitive to cultural standards and practices as given in the cultural guidelines for each country in which we work.
3. Remember that I have come to learn, and serve: You may run across procedures that you feel are inefficient, or attitudes that you find closed-minded. You are to resist the temptation to inform our hosts about “how “I” do things.” You are to be open to learning other peoples’ methods and ideas.
4. Develop and maintain a servant’s attitude toward all nationals and my teammates.
5. Respect the work that is going on in the country with the particular church(es) or person(s) with whom we are working: Realize that our team is here for just a short while, but that the local church is here for the long term.
6. Be flexible and serve in whatever service area is allowed and open to me on the trip. (for example: doing dish, packing cars, holding flash-lights).
7. Abide by any additional guidelines which may be deemed necessary by the leaders during the event.

Financial Responsibility

By signing this application, I am indicating that I have decided to participate in the mission’s trip and I plan to obtain the funds (airfare + $200) necessary to do so. I realize that all moneys received will be submitted to International Dental Ministries and will be held in an account that goes toward the mission trip and all monies are non-refundable.
In the event that trip funds raised exceed trip costs, I understand that such excess funds may be used to cover other trip expenses. Gifts become the sole property International Dental Ministries. A gift to International Dental Ministries is a charitable contribution for federal income tax purposes to the extent permitted by law. Tax deductible gifts cannot be refunded. In the event I do not participate in the trip, gifts to International Dental Ministries will go to support other ministry activity costs.

Liability Waiver

I have read the application of International Dental Ministries, Inc. (IDM) and accept its provisions and agree to live work and serve in accordance with them. I, the undersigned, also realize that in accepting a term of volunteer service, it is with a clear understanding that IDM does not assume the responsibility for loss of my property, damage to the same, personal harm, illness, or death that may come to myself or those who travel with me. I, for myself, my heirs, executors, administrators, and assigns, in consideration of my admission to volunteer service and other good and valuable considerations, do hereby release and forever discharge IDM, its directors, officers and employees from liability for any
claim or demand which I or my heirs, executors, administrators or assigns, might otherwise assert upon the basis of any of the forgoing. In volunteering, I recognize that I do not become an agent or employee of IDM in rendering my services and I agree to hold IDM harmless from any claim that might arise out of any acts performed by me while serving as an IDM volunteer.

Participation of a Minor

If the participant has not attained the age of 18 years go to the attached link for the proper documents necessary for travel with International Dental Ministries.

Minor Document

Participant Signature & Date
If under 18 parent(s) signature required

Signed:

Dated: