Test: Application Form Applicant InformationNameAs it appears on your passport. First Middle Last Suffix Date of Birth(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Highest degree or training at the time of the trip Home Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Email(Required) Phone(Required)Shirt size(Required)All shirt sizes are unisex.SmallMediumLargeX-LargeCountry of Citizenship(Required) Passport Number(Required) File(Required)Please attach a high-resolution scan of the identification 2-page spread of your passport.Accepted file types: jpg, png, pdf, Max. file size: 512 MB.Emergency Contact InformationName(Required) First Last Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Email(Required) Phone(Required)Your InterestDestination(Required)Uganda I – April 10 – 18, 2026Uganda II – July 3 – 11, 2026Uganda III – July 10 – 18, 2026Kenya 2026Why this trip?(Required)Describe why you are interested in participating in a M2H expedition. If you are a college student, please indicate your career ambitions.Your Education, Training, and Skills(Required)Please describe your education level, your occupation or profession, and any training or skills relevant to this trip (e.g., medical, construction, farming, mechanical, languages other than English). This information is often needed by M2H when applying for letters of invitation or permission to enter a host country to conduct a medical mission.Your Experience(Required)Please describe any previous mission experience, any similar travel experiences, and/or any examples of living in under-resourced conditions (i.e., roughing it).Your Health(Required)Please list any conditions or issues that may hinder your ability to serve as a member of one of our teams. Mission to Heal field teams often travel to remote and physically demanding environments. Your contributions to our efforts may include, but will not be limited to: lifting and carrying of supply bags weighing 50 lbs. or less, transportation of patients by stretcher, traveling long distance by automobile, forgoing a normalized meal schedule, and generally adapting to a resource poor and or high stress environment. Your safety is our obligation. An inability to perform the above tasks is not necessarily grounds for exclusion.Additional DocumentationLicensesIf you are a medical professional, please attach a copy of your appropriate licenses.Accepted file types: jpg, pdf, png, jpeg, Max. file size: 512 MB.Resume / C.V.Please attach a resume or C.V. that details your experience and expertise.Accepted file types: pdf, doc, docx, Max. file size: 512 MB.Yellow Fever VaccinePlease attach a copy of your yellow fever vaccineAccepted file types: pdf, doc, docx, jpg, png, Max. file size: 512 MB.Volunteer CommitmentsWe are grateful to the dozens of volunteers who donate their time, talent, and energy to missions each year. As a nonprofit organization, Mission to Heal works in partnership with volunteers to ensure that the burden of cost is not transferred to the patients we serve.Application Deposit(Required)To be considered for a M2H expedition, you must submit this application along with a deposit of $100 which counts towards your overall fundraising commitment. If you are denied acceptance, or if you must withdraw from the proposed mission, the deposit will not be refunded. You may use the deposit in a later application for a trip; otherwise, we will both consider it a donation. I consent Mission Volunteer Fee is $2,000(Required)The Mission Volunteer Fee is $2,000 USD. This amount supports Mission to Heal in addition to covering the cost of food, lodging, transportation, medical supplies, and fuel for the Mobile Surgical Unit. Mission to Heal provides a fundraising toolkit and supports each volunteer in raising this amount. The $2,000 fee is due 30 days prior to the start of the mission. I consent Volunteer Experience Evaluation Form(Required)I acknowledge that a post-mission evaluation is required of me and must be submitted within 2 weeks of the trip’s completion. Failure to complete this reflection will result in receiving no credit for this mission, regardless of performance, and will be noted in any letter of recommendation on my behalf. I consent Media Release(Required)I grant Mission to Heal the right to use my photographs, video, and reflection essay as well as other photos and videos taken of me from this trip in print and digital form with or without my name for any lawful purpose, including publicity, advertising, and web content. I consent By signing this application, I, along with all members of my family, do hereby voluntarily waive any and all claims for any reason against Mission to Heal (DBA Mission2Heal), or its officers, leaders, and associated institutions or sponsors. By signing this application, I also certify that to the best of my knowledge, I am physically and mentally able to participate in a Mission to Heal expedition.Applicant's Digital Signature(Required) First Last Date(Required) MM slash DD slash YYYY Guardian's Digital SignatureIf applicant is a minor. First Last Date MM slash DD slash YYYY