Register For Medical Trips

Register for upcoming Medical Trips with Hope Christian Health Center.

Fill out the form below to register today..

PERSONAL INFORMATION

Your careful attention to this Medical Reference Form is vital. You have applied to participate in an intense medical and volunteer trip in Côte d'Ivoire. Your medical evaluation of the your physical condition and mental stability is essential in determining your suitability for this trip. This medical data will also enable medical professionals in Côte d'Ivoire to appropriately address any medical emergencies that you may face during the trip. Please let us know if you have any questions or doubts as you fill out this form!

First and Last Name(Required)

Email Address(Required)

Phone(Required)

Date of Birth(Required)

Street Address(Required)

City(Required)

State(Required)

Zip Code(Required)

Trip of Interest(Required)

December 26, 2026 – January 5, 2027; Alépé, Côte d’Ivoire

Professional Experience(Required)

MD, DO, DDM, OD, DPT, PharmD

PA, NP

RN, LPN, dental hygienst

Medical, dental, PT assistant

Health Educator

Engineer -- Water and sanitation

Translator

Health grad/ professional student

Health undergrad student

Other

Profession(Required)

Church Attended(Required)

Have you ever taken part in an international trip before?(Required)

Yes

Age(Required)

Medical History and Questionnaire

Medications & Dosage(Required)

Allergies(Required)

History of Severe Injuries and Surgeries(Required)

Physical, Mental, or Emotional Limitations(Required)

Within the past five (5) years, have you been diagnosed with or treated for any medical conditions in the following areas.

Eyes/Ear/Nose/Throat(Required)

Yes

Mouth/Teeth(Required)

Yes

Immune(Required)

Yes

Cancer/Tumors(Required)

Yes

Neurological(Required)

Yes

Transplants(Required)

Yes

Arthritis(Required)

Yes

Bone/Muscles/Joints(Required)

Yes

Psychological(Required)

Yes

Diabetes/Endocrine(Required)

Yes

Reproductive(Required)

Yes

Lung/Respiratory(Required)

Yes

Live/Kidney/Urinary(Required)

Yes

Digestive/Intestinal(Required)

Yes

If "other" please explain below(Required)

For all “YES” answers, provide details in space provided.(Required)

Do you currently have

Any abnormal test, or physical examination results(Required)

Yes

Any health condition, illness or injury that may require treatment(Required)

Yes

Any use of tobacco products(Required)

Yes

Any dietary requirements that may be a challenge to foreign work or travel(Required)

Yes

Any weight or mobility difficulties that may be a challenge to foreign work or travel(Required)

Yes

Any medical devices, equipment, braces, or prostheses that are used regularly(Required)

Yes

Any physical or medical limitation to lengthy air or vehicle travel(Required)

Yes

Any physical or mental condition that may impact possible roommates(Required)

Yes

Any restrictions due to physical or mental health conditions(Required)

Yes

Please explain any “Yes” answers listed in the questions above with Diagnosis/Treatment, Diagnosis Date, and Treatment Status:(Required)

Please answer the following questions in regard to your general health and physical condition.

Are you capable of rigorous labor with lifting (30 lbs. or less), twisting, and bending?(Required)

Yes

Are you capable of walking long distances in hot, humid weather?(Required)

Yes

Do you live an active and healthy lifestyle?(Required)

Yes

Psychological Profile

Conditions imposed by a foreign volunteer program include absence from family and home, close quarter group living, extended hours of travel, new social contacts, and adjustments to cultural differences. The experience is physically and mentally stressful and moves individuals out of their comfort zone.

Please answer the following questions in regard to the your general psychological profile:

Are you a positive, flexible, and agreeable person?(Required)

Yes

Are you capable of working and living with others?(Required)

Yes

Do you have any history of mental disorder or difficulty?(Required)

Yes

Do you have any history of being treated by a psychiatrist, psychologist, or professional counselor?(Required)

Yes

Have you used or currently using tranquilizers, anti-psychotics, anti-depressants, etc?(Required)

Yes

Do you have any history of addictions or the use of addictive substances?(Required)

Yes

By clicking the Yes, I hereby certify that the statements and answers I am providing in this form are true and correct to the best of my knowledge and belief, and that I understand that statements or information furnished in this application are subject to verification.(Required)

Yes

Date(Required)

Month

Day

Year

Time(Required)

Hours

Minutes

AM/PM

For the patient to complete and sign: I authorize the leadership of Hope Christian Health Center. and their assigned representatives to release the above-described medical information to medical facilities or medical practitioners solely for use in my evaluation as an applicant or my medical treatment as a participant in the Côte d'Ivoire June 2026 Medical Mission trip under the direction of Hope Christian Health Center.

Name(Required)

Date(Required)

Month

Day

Year

Time(Required)

Hours

Minutes

AM/PM

Pastoral Reference (to be completed by your Pastor)

Applicant name:(Required)

Your relationship to the applicant(Required)

Pastor

Ministry Leader

How long have you known the applicant?(Required)

Less than six months

Six months to a year

One to five years

More than five years

Other

Have you observed the applicant in ministry?(Required)

Yes

Other

Is the applicant capable of working well with others?(Required)

Yes

Other

Does the applicant have a history of alcohol or illegal drug use?(Required)

Yes

Other

Would you accept this person on a ministry trip you were planning?(Required)

Yes

Other

Please explain why you think the applicant should or should not participate?(Required)

Message

Please read carefully before signing. This is a legally binding agreement.

This Volunteer Release and Waiver of Liability ("Agreement") is entered into by the undersigned Volunteer ("Participant") in favor of Hope Christian Health Center (HCHC), its officers, directors, employees, agents, volunteers, missionaries, partners, and affiliates.

1. ACKNOWLEDGMENT OF RISK

I understand and acknowledge that participation in the June 2026 Medical Mission Trip to Côte d’Ivoire involves inherent risks, including but not limited to:

International and domestic travel by air, land, or sea
Medical and clinical activities in low-resource environments
Exposure to infectious diseases, illness, or injury
Political instability, crime, or civil unrest
Environmental hazards and weather conditions
Limited access to emergency or specialized medical care
Acts of God

I voluntarily choose to participate with full knowledge of these risks.

2. ASSUMPTION OF RESPONSIBILITY

I accept full responsibility for my participation and any injury, illness, loss, or damage that may occur as a result of my involvement, whether caused by negligence or otherwise, except in cases of gross negligence or willful misconduct.

3. RELEASE AND WAIVER OF LIABILITY

I hereby release, waive, discharge, and covenant not to sue Hope Christian Health Center or its representatives from any and all claims, demands, losses, damages, or liabilities arising out of or related to my participation in this mission trip, including travel to and from the destination.

4. MEDICAL TREATMENT AUTHORIZATION

I authorize Hope Christian Health Center and its representatives to obtain medical treatment for me in the event of injury or illness during the trip if I am unable to give consent. I understand that I am financially responsible for any medical expenses incurred.

5. INSURANCE RESPONSIBILITY

I acknowledge that I am responsible for obtaining adequate medical, travel, and evacuation insurance for the duration of the trip. I understand that Hope Christian Health Center does not provide insurance coverage for participants unless otherwise stated in writing.

6. BEHAVIOR AND COMPLIANCE

I agree to comply with all rules, instructions, safety protocols, and standards of conduct set by Hope Christian Health Center and trip leadership. I understand that failure to comply may result in dismissal from the trip at my own expense.

7. PHOTOGRAPHY AND MEDIA RELEASE

I grant permission for Hope Christian Health Center to use photographs, video, audio recordings, or other media taken during the trip for promotional, educational, or informational purposes without compensation.

8. CHRISTIAN MISSION ACKNOWLEDGMENT

I understand that this trip is a Christian medical mission. I agree to conduct myself in a manner consistent with Christian values and to respect the spiritual and cultural context of the mission.

9. BINDING AGREEMENT

I certify that I am at least 18 years of age (or have parental consent if under 18), have read this Agreement in its entirety, understand its contents, and sign it freely and voluntarily.

By clicking the SUBMIT button, I hereby certify that the statements and answers I am providing in this application are true and correct to the best of my knowledge and belief, and that I understand that statements or information furnished in this application are subject to verification.

Thank you for your time and input.