Participants Name
*
First Name
Last Name
Birthdate
*
Age
*
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email Address
*
Phone
*
What church do you attend and how long have you attended?
*
Church Website or Pastor's Email Address:
Please check one:
*
In what capacity are you hoping to come to IHSI/Sak Saum?
*
When are you hoping to come?
Name
*
First Name
Last Name
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email
*
Phone
*
Father or Guardian
First Name
Last Name
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Mother or Guardian
First Name
Last Name
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Please list any physical limitations, handicaps, or medical conditions that you have:
Please list any allergies that you have (environmental, food, medication, etc):
Please list any dietary restrictions or atypical diet regimes (vegetarian, vegan, etc) that you observe:
Please list any medications you are taking (prescription or over-the-counter):
Do you smoke/use tobacco?
*
Do you drink alcohol?
*
Are you under the care of a doctor?
*
If you answered "yes" to any of these questions, please explain below.
Please answer the questions below
*
Please list your spiritual gifts, natural abilities, and skill set to the best of your knowledge:
What do you feel are your personal strengths and weaknesses? Please list both:
What kind of life/study/work experiences have you had that may be applicable to your time in Cambodia?
Insurance Provider
Policy Number
Participants Electronic Signature
*
Date
*
MM
DD
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