Medical Relief International
Providing Aid to Countries in Need
Where we go
Myers Clinic Progress
Barikiwa Health Center
Barikiwa Health Center Progress
Cinco de MRI
Philippines - Islands
Philippines - Manila
What to Expect
Please fill out the following form for MRI records
Full Name as it appears on passport
Passport Number - 0123456789
Passport Expiration Date
Country of Issuance
Are you a US citizen?
Zip Code - ex. - 98001
Phone Number - ex. - 555-555-1212
How did you hear about Medical Relief International?
Do you have any physical limitations or medical conditions that would prevent you from safely doing the task you are applying for? If yes, please explain
Have you ever been charged with or convicted of any crime including either a felony or a misdemeanor? If so please describe.
Are you retired or semi-retired?
Education & Experience
Education (Major Subjects)
Foreign Languages - Please include degree of fluency (Novice, Intermediate, or Fluent)
Previous international or cross-cultural medical work or mission experience
Past or present churches, civic or auxiliary affilications, volunteer experience
Emergency Contact Info
Emergency Contact Name 1
Emergency Contact Phone Number 1
Emergency Contact Name 2
Emergency Contact Phone Number 2
Please print off the Medical liability release form.
Please sign and fax to 425-556-1333
Doctor's Phone Number
Health Insurance Company
Insurance Phone Number
Thank you for submittion your information. If you have any questions or concerns, please contact:
12316 134th Ct NE
Redmond WA 98052
Powered by BreezingForms