Application Deadline January 19, 2004

Give this completed application along with a $100 deposit to your campus staff person or mail to:

Full Name (exactly as it will appear on your passport):

Name you go by: ____________________________

School/Employer Name: ________________________________________

Program/Specialty? (check one) O Medical   O Dental   O Allied Health (PT/OT)  O Pharmacy   O Nursing   O Other

Address at School: ________________________________________________________________________________

Class/Graduation Date: _______________

Date Leaving This Address (if leaving for summer): __________

Are your parents supportive of your participation in this SMI? (we like to send an info letter to parents with flights, etc)

                                                                   O yes     O no     O haven't discussed it

Parent Name(s): ___________________________________   Phone: _______________________________________

Parent(s) Address:________________________________________________________________________________

T-Shirt size: O Small      O Med      O Large      O X-Large

Do you have passport? O yes O no
(If yes, please attach a copy. If no, you will need to apply immediately. Applications are available at the post office.)

Please answer the following questions to help us learn more about your attitudes and beliefs.
What, briefly, is your understanding of what it means to be a Christian?

Would you describe yourself as somebody who is investigating the claims of Christ" or growing in a relationship with Christ?

Are you willing to be involved in Bible Study? Are you willing to learn how to incorporate health care into a Christian life/world view? Why do you want to participate in the SMI this year?
 

Are you willing to build a support team for your trip (those who support you with the financial cost, prayer, and encouragement) ?  O yes      O no

What a person believes is the foundation for life and ministry. If you have any objections to the above statements that would prevent you from participating, please list them on the back of this paper.

1.To meet the physical, emotional, and spiritual needs of the people of South Africa through the practice of medicine and by sharing the Gospel of Jesus Christ with them.

2. For participants to grow in a relationship with Christ and in doing so to be better equipped to meet the physical, emotional, and spiritual needs of their patients.

1. Due to the number of students, conditions of project, and foreign culture, our students, physicians and staff will need to set aside some of their personal preferences, habits, and schedule to fulfill the mission of the summer project.
2. SMI South Africa is an inter:-denominational ministry that uses Holy Scripture as its sole authority. We understand that there are variations in practice and understanding of Scripture in some areas of Christian living. In order to provide an environment that is conducive to meeting the above purpose, participants will agree to abide by the standards of SMI in areas such as dress, entertainment, activities, etc. We expect participants to not engage in alcohol, drug, or tobacco use and to be a willing participant in all cultural, regional, church, & SMI activities with sensitivity to cultural and SMI standards.
3. In cooperation with the SMI, participants will seek to provide excellent medical care and to represent Jesus Christ.

I have read the SMI application and accept its provision and agree to live, work and serve in accordance with them. I, the undersigned, also realize that in accepting a term of volunteer service, it is with the clear understanding that SMI does not assume responsibility for loss of my property, damage to the same, personal harm or illness that may come to those who travel with me or myself. I, for myself, my heirs, executors, administrators, and assigns, in consideration of my admission to volunteer service and other good and valuable considerations, do hereby release and forever discharge SMI from liability for any claim or demand that I or my heirs, executors, administrators or assigns might otherwise assert upon the basis of any of the foregoing. In volunteering, I recognize that I do not become an agent or employee of SMI in rendering my services, and I agree to hold SMI harmless from any claim that might arise out of any acts performed by me while serving as an SMI volunteer.

________________________________________________________________________________________

Signature of Applicant for Summer Medical Institute, Volunteer Service

________________________

Social Security Number