Medical Mission Application

GENERAL REQUIREMENTS

To submit a completed Aid Project Proposal, please be sure and include the following:

Letter from your Bishop approving and endorsing your project and addressed to:

To ensure IMF operates with the full knowledge and support of the local Catholic leadership, this
letter must include the name and location of your project, its estimated duration (ex:
6months/1year/etc) and approve IMF to assist with the project both remotely and onsite. Please
include a copy of this letter when submitting your application to IMF.

All sections of this application must be fully completed in order for IMF to review the proposal.

Please include 5-7 pictures of the project area/building, beneficiaries

Please ensure that a project proposal and all attachments are legible. IMF recommends that you also
keep a copy of your proposal for your own records. Once all parts of the application process are
completed, you may either scan and email us your proposal or post it to the address below.

International Missionary Foundation info@imfmissions.org

Medical Mission Proposal Fax: 1.970.616.0674
PO Box 8 Please include the subject title as, Medical
Greeley, CO 80632 Mission Proposal, + Your Town Name
USA (e.g. Medical Mission Proposal, Jimeta)

Once your application is received is completion, IMF will contact you to advise on next steps. We aim to
respond within 7-10 business days of receiving full and complete applications.

We look forward to hearing from you soon.

God Bless!

-IMF

International Missionary Foundation

 MEDICAL MISSION REGISTRATION FROM
Contact Details

Name of Primary Contact: Contact Number or Email:

Name of Hospital or Clinic: Country:

Hospital Address:

Hospital Phone: Hospital Fax (if appropriate):

Hospital E-mail (if appropriate):

Name of Bishop: Bishops Contact Number or Email:

MEDICAL MISSION PROPOSAL

Project and/or Mission Summary

Please describe the specific project or medical needs that you are requesting assistance with and be as detailed as possible:
Project/Mission Categories (please tick all that apply):

Medical Mission Medical Supply Mission Medical Training Mission

(ie- Doctors/Nurses needed) (ie- Medical equipment/supplies (ie- Need additional medical training)
needed)

Medical and Optical Dentist Doctor, Public Health/Health and

Health Services Services Services Nurse, or Surgical Sanitation/Hygiene Training
(ALL) Services

Please answer the following questions:

Community Background
About how many people live in your community?

What medical resources do you currently have?

How will this medical mission impact your community?

Is your community able to provide short term food

for IMF volunteers/staff if onsite for a project or Yes No Maybe
mission?
Is your community able to provide short term
housing for IMF volunteers/staff if onsite for a Yes No Maybe
project or mission?
Is your community able to provide transportation
for IMF volunteers/staff if onsite for a project or Yes No Maybe
mission?
Is your community able to provide access to power
and electricity during a project or mission? Yes No Maybe

Is your community able to provide access to

internet and phone coverage during a project or Yes No Maybe
mission?
 Project Objectives and Expected Results
What do you hope to gain from the project?

Project Factors
Please answer the following questions as honestly as possible:
Safety Hazards

Political/Social Natural Disasters Terrorist or war Health risks: water, food

unrest activity or environmental
If youve checked any of the above answers, please explain:

Are there any other physical hazards in your community or region:

Project Budget Information

Please estimate percentage (%) of total.
Please estimate dollar ($) amount A,B &C combined should equal 100%.

$____________ _______/100%
A. Community Contribution
$____________ _______/100%
B. Proposed IMF Contribution
C. Other Sources of Financial
$____________ _______/100%
Contribution
Estimated Project Expenses
Please estimate dollar ($) range (e.g. $400-600)
1. Personnel / Labor Costs $________________________
2. Equipment / Materials $________________________
3. Food/Housing Costs $________________________
4. Travel/Transportation $________________________
5. Other costs (please name):

Total Estimated Project Cost $

Available Start Date for Project: _______________________________________

Estimated Duration of Project: ________________________________________

I, __________________________, hereby do agree that the information contained on this form is correct and accurate to
the best of my knowledge. I give International Missionary Foundation (IMF Missions) and its staff permission to record
these details and to contact me in response to the information contained in this application.

____________________________ _______________________________ _____________

Printed Name Signature Date