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ORH APPLICATION FORM

YOUR OWN DETAILS

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YOUR EMERGENCY CONTACT DETAILS

CHURCH INFORMATION

REFERENCE

GENERAL HEALTH

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THE APPLICATION QUESTIONS ARE MEANT TO HELP ORH PROPERLY GIVE YOU THE
CORRECT GUIDANCE AS TO PARTICIPATION WITH A MEDICAL TEAM. IF YOU CHOOSE NOT
TO ANSWER, ORH WILL NOT COMPEL YOU TO ANSWER.

APPLICATION QUESTIONS

Have you had surgery or been hospitalized within the last year?
Do you have heart trouble?
Do you have allergic reactions requiring immediate attention?
Do you have allergic reactions to insect stings?
Do you have life threatening health problems requiring close monitoring?
Do you have diabetes?
Do you have a debilitating health problem requiring hospitalization?
Do you have a problem with seizures?
Do you have health problems requiring special treatment?
Do you have problems with diagnosed with depression?
Are you currently taking medication for depression?
Do you take medicine to thin the blood?
Are you pregnant at this time or will you be pregnant at the time of travel?
Have you ever attempted suicide?
Have you ever lost track of time or lost knowledge of who you are?
Do you have problems with fainting?
Have you had episodes of sea sickness or fear of being on the water?
Can you swim?
Have you had episodes of motion sickness?
Do you have problems with traveling by air?
Do you have phobias that cause some type of panic reaction?
Have you been arrested for any reason?
Have you ever broken the law and been prosecuted?
Have you ever been convicted of a crime?
Have you ever been charged with DUI?
Have you ever had an episode of violent behavior?
Have you ever been investigated for child abuse or domestic violence?
Have you ever hurt someone in anger?
Have you ever been investigated for child pornography?
Have you ever been investigated for child molestation?
Have you ever been expelled from a school?
Are you presently being sued for malpractice?
Do you use illegal drugs or legal drugs illegally?
Do you use Tobacco in any form?
Do you use profanity?
Do you drink any type of alcoholic beverage?
Can you work with teen-age student trainees?
Are you willing to pay your own expenses for medical trips?
Do you attend church regularly?
Are you able to endure discomfort, poor food, rough ocean travel, and air flights?

INSTRUCTIONS

This application must be returned as an email attachment to djones@teamorh.com

If you are a medical professional, please copies of the following:
1. color copy of all medical degree diplomas.
2. any certificates.
3. current license(s).
4. documents concerning your academic or professional accomplishments.

All applicants must send a color copy of the photo page of your passport.
ORH must receive a completed Medical and Liability Release Form when requested prior to
travel. Directions for submission must be followed as outlined on the form.

ORH requires that you read and agree to abide by the Standard Clinic Operations Procedures manual.

No person may consider themselves approved for travel with ORH unless all requested
documents including this application are submitted, on file, verified, and approved by ORH.

Applicants will receive an email informing them of their approval to engage with ORH. No person may assume they are approved until they have notification. Thank you for your prompt attention
to these matters

Thank you for submitting. We'll be in touch soon!

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