The Luke Commission | Compassionate Medicine

Dates available for service in Swaziland:

Arrival Date: 

Departure Date: 

Title: 

Last Name: 

First Name: 

Middle Name: 

Marital Status: 

Is this your passport name?

Please enter passport name if  different from above here: 

Birth Date: 

Sex: 

Place of Employment: 

Occupation: 

Work Phone: 

Home Phone: 

Cell Phone: 

Home Address: 

City: 

State: 

Zip Code: 

Email: 

Home Church: 

Pastor: 

Church Address: 

Church Phone: 

Denomination/Affiliation: 

Would any children be accompanying you?

If so, please list here: 

May we add you to our monthly email newsletter list? 

Emergency Medical Information

 Allergies:

Current Medications: 

Doctor’s Name: 

Doctor's Phone: 

Last Tetanus Shot: (as exact as possible)

Health Insurance Provider: 

Emergency Contact: 

Relationship: 

Day Phone Number: 

Evening Phone Number: 

Alternate Emergency Contact:

Relationship: 

Day Phone Number: 

Evening Phone Number: 

Travel Document Information

Do You Have a Passport? 

Passport Country: 

Where was it issued? 

Passport Expiration: 

Passport Number: 

Citizenship: 

City & State of Birth: 

Country of Birth: 

Experience & Qualifications

How did you hear about The Luke Commission? 

Have you ever traveled outside the US?

Why do you want to go on this trip? 

Do you speak any foreign languages? If so, please list: 

List any cross-cultural mission experiences you have had: (Please include country, organization and dates) 

List other formal ministry experience you have had: (Please include organization, responsibility, and dates)

List any leadership positions you have held: (Please include organization, responsibility, and dates)

Do you enjoy working with children? 

What skills and/or experience do you have that might be useful on this mission trip?

Do you have any training/background/certification in any medical profession (i.e. doctor, nurse, R.Ph., EMT, PT, ENT, Chiropractor, etc)?

Will you be raising funds for some or all of your expenses for this trip?

Describe for us your spiritual condition and/or tell us your faith story:

Is there any other information that we should know about (felony convictions, legal matters, etc.)?   

Is your name listed on any sex offender registry in any state in the U.S.?

Physical Requirements

It is our desire that as many people as possible go on our teams, however, our work can be physically demanding. The experience of a foreign mission trip can be taxing on even the hardiest individuals. To determine whether or not this trip is right for you, please see the list below.

• Ideally you should be able to walk one half mile over uneven ground surfaces. You also need to be able to manage your own luggage and occasionally help with physical set up of the clinics. 
• If you have any medical conditions, please visit your physician to get his or her blessing to travel with us. Make sure that your physician understands that you will be confined in the airplane for up to 18 hours
• Ask your doctor if they recommend anything to prevent blood clots on the flight such as aspirin or exercises in your seat. If you are bringing prescription medications, please make sure you follow all airline guidelines and restrictions for bringing those medications.
• If there is any question about your health, we may require a medical release from your physician.
• If you have any psychological conditions, please discuss this with your physician before committing to one of our teams. Please make us aware of any condition, even if it is well controlled.

Health Information  

(Answer Yes or No for each of the following questions.) 

Are you currently being treated for any sickness or injury? 

Are you allergic to any medications? 

Do you have any other allergies? 

Have you ever had an eating disorder? 

Are you required to be on a special diet? 

Do you ever sleep walk or have sleeping problems? 

Do you get nervous or upset easily? 

Have you ever had psychiatric care? 

Have you ever been treated for depression? 

Do you have any physical disabilities that would keep you from participating in normal or rigorous activities? 

Do you have or have you ever had a seizure disorder? 

Do you have or have you ever had asthma or other breathing problems? 

Do you have or have you ever had a heart murmur? 

Do you have or have you ever had a kidney disease? 

Do you have or have you ever had diabetes? 

If you answered yes to any of the previous questions, or if you have been diagnosed or treated for any mental or psychological illness or disorder, please give an explanation below.  

Self Evaluation

On a scale of 1-10 (10 being the highest), please evaluate yourself in the following areas:

Relating to New People: 

Finishing what you start: 

Problem solving: 

Submission to leaders: 

Organization/planning: 

Public/group speaking: 

Confronting: 

Listening: 

Leadership: 

Encouraging: 

Receiving correction: 

Trying new things: 

One-on-one ministry: 

Taking charge/giving directives: 

Describe three strengths (not necessarily from the above list):

Describe three weaknesses (not necessarily from the above list):

Have you been involved in any of the following within the past year? 

Tobacco 

Alcohol  

Illegal drugs 

Gang-related activities 

A cult or the occult 

If yes to any of the above please explain:

References 

Name: 

Relationship: 

Phone Number: 

Email: 

Name: 

Relationship: 

Phone Number: 

Email: 

Name: 

Relationship: 

Phone Number: 

Email: 

Final Agreements