Medical Mission Application Medical Mission Application Step 1 of 5 - Personal Info 20% CCO MissionsThank you for considering CCO Missions! Please note, that it is possible that you may not hear back from us in regards to your acceptance until after the application deadline.Personal InfoPlease enter your name:* First Last Sex* Female Male Your birth date:* Month Day Year Email* Phone*Phone Number Address* Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Country or countries of citizenship* What languages do you speak fluently?* English French Spanish Do you speak additional languages? Please list them. Briefly outline your experience in CCO?* Have you taken any CCO faith studies? Which ones?* Discovery Source Growth Trust (Obedience) Commission I haven't taken any CCO faith studies Have you led any CCO faith studies? Which ones?* Discovery Source Growth Trust (Obedience) Commission I haven't led any CCO faith studies What type of Medical Professional are You?DoctorRegistered NurseLicensed Practical NurseNurse PractitionerDental SurgeonDentistDental HygenistOtherStudentWhich? Where are you studying? What are you studying? Year of Study What is your specialty/area of expertise? Please provide a brief descripiton.What professional governing body are you licenced with? What is your licence number? Do you have any surgical or/OR experience? If yes, please describe below.Do you have any experience with medical missions? If so, please describe below.Have you ever worked in a developing country? If so, where?Are you comfortable working in the following areas? Surgeon Surgical Assistant Scrub Nurse Anesthesiologist Pre-Op Post-Op/PACU Are you physically fit to perform the volunteer role to which you are applying? Do you have any of the following conditions: Asthma, COPD, dvt, Diabetes, stroke, MI, epilepsy, anxiety or depression, bleeding disorder, or other health concern, bleeding disorder?Have you had any recent hospital visits as a patient? (Last 6 months) More about yourself Tell us about yourself; we want to get to know you. Don't be afraid to be concise!What are you presently doing (working, university student, what you are studying at school, etc.), and what are your hobbies and interests?*Why do you want to be a part of this mission? Please include specific goals and objectives.*Describe your faith journey and who Jesus is in your life. Would you say that you know Jesus in a personal way? Describe your spiritual life, including when and how you pray, the sacraments, and what spiritual resources you may be using.*How do you feel about the teachings of the Catholic Church, and the Pope? Is there anything you would change?*On all CCO missions the following activities are standard: praise & worship, daily personal prayer, 1-on-1 evangelization, and sharing your testimony. Are there any of these that you are hesitant to participate in?*Describe in your own words what "evangelization" means. Comment on how you go about sharing your faith with others.*Are you willing to participate in: one-on-one evangelization, door-to-door evangelization, large group presentations (skits / MCing / singing), giving your personal testimony, speaking in public. Is there any that you would not be willing to do/try?*Describe any ministry related leadership experiences you have both within CCO other groups. (i.e. leading small groups, organizations, etc.).* Social History and Health InformationOn the mission, whether ministering or just socializing, you will be seen as a representative of Catholic Christian Outreach and a person in ministry. Your life will need to be a model for others; therefore, we need to be confident that you demonstrate consistent Christian character and have the highest moral standards. These questions are not intended to be intrusive but come from our experiences with previous missions and are designed to help us gain a full understanding of you and to ensure that this mission is a fit for you. The answers that you give are held strictly confidential. A past problem in any of the following areas does not necessarily disqualify you from this mission.In the last 6 months have you used narcotics, hallucinogenic drugs or drugs not prescribed by a physician?* No Yes If yes, please expand.*Are you willing to give up any social habits that might lessen your effectiveness and influence on the mission?* No Yes Do you have any health conditions or concerns (physically, emotionally, mentally) that could cause difficulties for yourself or the mission. For example: allergies, physical limitations, eating disorders, reactions to heat, medications your taking, anxiety, depression, panic attacks, or moodiness.* No Yes If yes, please explain.*Have you recently or are you currently struggling with an addiction of any kind? (e.g. alcohol, drugs, pornography, etc)* No Yes If yes, please explain.*Have you ever been convicted of a criminal offense?* No Yes Is there any reason that you would be uncomfortable with, or unable to work with children or youth?* No Yes if yes, please explain*Have you over the past 6 months been obedient to the Church's teaching on chastity?* No Yes In the past 6 months have you fulfilled your Sunday obligation by attending Mass every weekend?* No Yes If accepted, you will be given access to a site that provides a number of resources to help you prepare for mission. To access this site, you will need an email that is associated with a Google account. Which email address would you like to use to access this site?* Are there any other comments that you would like to include in your application? ReferencesPlease supply contact info for two references. One contact should be a CCO staff member. However, if you are unable to provide a staff reference, a reference from your pastor will be accepted. Reference (1)* First Name Last Name Is this reference a CCO staff member?*YesNoRelation to you (1)* Email (1)* Reference (2)* First Name Last Name Is this reference a CCO staff member?*YesNoRelation to you (2)* Email (2)* Reference (3)* First Name Last Name Is this reference a CCO staff member?*YesNoRelation to you (3)* Email (3)*
