PLEASE PRINT or TYPE

Personal Information:

Name:_____________________________________________________________________                                                                      

Mailing Address:_____________________________________________________________

City, State/Province:_________________ Zip Code:_____________  Country:__________ 

Name of the airport(s) to which you have access__________________________________ 

Home phone:____________________     Cell phone:____________________

Work phone:____________________      FAX number:____________________

 e-mail address: _____________________________   

Date of Birth: ________________________

Citizenship: ______________________Sex: ____________

Marital Status: ______________     Name of  Spouse: _______________________________

Spouse's Date of Birth: _________________________

Names and Ages of Children________________________________________________________________________

Home Church: _______________________________Telephone: (      )_____________

Address:  ______________________________________________________________

Pastor's Name: _______________________Pastor's  Telephone: (      )____________

Health:

The mission of GANSU, INC is to provide eye care through teaching and surgery to the underserved people living in the remote areas of provinces in west China and Tibet.  Some parts of these provinces are at very high altitude and some of the passes required in traveling to these areas exceed 12,000 feet.  In addition to potential health difficulties related to the altitude, general health and sanitation norms are well below the standards expected in the United States. Medications may be difficult or impossible to obtain in a timely fashion.

Please answer the following questions in the context of the above prefacing statements.

Do you take any prescription medications on a regular basis?  Yes _______ No ________

If “Yes”, what?__________________________________________________________

Do you have a medical condition that might place limitations on your work in circumstances such as outlined in the prefacing paragraph above?  Yes _____ No ______

If  “Yes”,  please  explain ___________________________________________________________________________________________


Occupation:

Profession: _____________________________Specialty: _______________________

Board Certification: ______________________________________ Year: ___________

Licensing: _____________________________________________________________
                           State or Province 

Present  position or occupation: ____________________________________________
 

References: Please provide the names, addresses, and telephone numbers of two people who know you in a professional capacity, as well as the same data for two non-family members, other than your pastor, who we can contact for personal reference.              

1. Professional:_________________________________________________________________________________________________

2. Professional:_________________________________________________________________________________________________

1. Personal:____________________________________________________________________________________________________

2. Personal:__________________________________________________________________________________________________            

 
Person to notify in case of  emergency:

Name: _________________________________Relationship: ____________________

Address: ______________________________________________________________ 

Daytime Phone: (      )_______________     Evening Phone: (      )_________________

 
Volunteer Information:

Previous experience in foreign countries: ___________________________________________________________
 
Length of time you can volunteer: ___________________________________________

Dates available: From _______________________To___________________________

Alternate dates: From _______________________To___________________________

Use a separate sheet of paper and write a short narrative indicating the following:

            1. How you learned of GANSU, INC.

            2. What you feel you could best contribute to its work.

            3. What would be your personal  goals from involvement with GANSU, INC?

            4. What would be your professional goals from  involvement  with this mission?

            5. Include a statement of your conversion experience, your spiritual beliefs, and what spiritual goals could be realized from              affiliation with this China project.


All Volunteers Must Return This Completed Form with: a copy of the photo and informational page of your passport, the answers         to the above questions, a copy of your State Professional License (Medical professionals only) and your Curriculum Vitae (Doctors only).
 

Signature: ________________________________________Date: _____________

Thank you for your interest!