Community Health Evangelism
Internship Program Application
HOLISTIC COMMUNITY DEVELOPMENT & INITIATIVES (HCDI), Inc.
Tuada Compound, Katipunan Street Ext., Mohon II, Tisa, Cebu City 6000, Philippines
Tel. No. +63-32-2621614, E-mail: rtvictorio@yahoo.com; or
hcdiphilippines@gmail.com
2x2 picture
DATE:
1. NAME:
Last
First
DATE OF BIRTH:
Age:
Middle
(
) MALE
( ) FEMALE
2. HOME ADDRESS:
(In full)
Use commas as needed
3. HOME TELEPHONE: Country/Area Code:
Number:
4. E-MAIL ADDRESS:
5. OFFICE ADDRESS:
(In full)
Use commas as needed
6. OFFICE TELEPHONE: Number:
FAX:
7. SPOUSE'S NAME:
First
Middle
Last
8. CHILDREN'S NAMES:
First
Middle
Age
First
Middle
Age
First
Middle
Age
9. LANGUAGES SPOKEN:
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10. EDUCATION:
Highest Level:
Degree(s):
11. LICENSING BODY:
12. ORDAINING BODY:
(If applicable)
13. OTHER TRAINING AND/OR CERTIFICATION:
Use commas (Accounting, Mechanic, Paramedic, etc.)
14. SECULAR WORK EXPERIENCE:
#1 Employer:
Inclusive Dates:
Job:
Location:
Reason for Leaving:
#2 Employer:
Inclusive Dates:
Job:
Location:
#3 Employer:
Inclusive Dates:
Job:
Location:
Reason for Leaving:
Reason for Leaving:
15. CHURCH MEMBERSHIP:
Church Name:
Pastor:
Church Address:
16. REFERENCES: 1-Pastor:
Address:
Yrs. Known:
2-Supervisor/Professional Associate:
Address:
Yrs. Known :
3-Friend:
Address:
Yrs. Known :
17. CHRISTIAN SERVICE:
From
To
1-
Ministry:
Mo.
Yr.
Mo.
Yr.
2Mo.
Ministry:
Yr.
Mo.
Yr.
Location: 4048 Tully Road ~ Modesto, California 95356 ~ info@med-amb.org ~ www.med-amb.org
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3-
Ministry:
Mo.
Yr.
Mo.
Yr.
Mo.
Yr.
Mo.
Yr.
4-
Ministry:
18. CHRISTIAN TESTIMONY: Briefly describe your life before Christ, when
and how you came to know Christ as your personal Savior and some of the
changes He has made in your life.
(Please attach an additional sheet with your testimony.)
19. CURRENT DEVOTIONAL HABITS: Briefly describe your current
devotional and prayer habits.
(Please attach an additional sheet describing your devotional habits.)
20. INTERNATIONAL EXPERIENCE: Briefly describe any international
experience you have had such as countries visited, reason for travel, etc.
(Please attach an additional sheet describing your international experience.)
21. Have you completed a TOT I? If yes, when and where did you complete
the training?
 YES
 NO
(When and where)
22. Do you have allergies and/or medical conditions that may affect your
ability to attend and carry out your duties in this program? If yes, please
list.
 YES
 NO
(Please list)
23. In what country or area do you intend to implement CHE? Please briefly
explain.
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24. Are you willing to live with a national host family while out in the field?
If not, please explain.

 YES
 NO
(Please explain)
25. In the space below, please explain why you want to be a part of our
internship program and how you plan to use your training.
Please explain what an integrated spiritual and physical ministry means to you?
.
(Use additional sheets if needed)
Location: 4048 Tully Road ~ Modesto, California 95356 ~ info@med-amb.org ~ www.med-amb.org
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CERTIFICATION AND ACKNOWLEDGEMENT
I certify that the facts contained in this application are true and
complete to the best of my knowledge. I understand that if I am accepted to the
Internship Program, any false statements on the application may be grounds
for non-acceptance to the program .
I authorize investigation of all statements contained in this application. I
also grant permission to contact all references listed above and authorize them
to release all information concerning my previous employment and any other
pertinent information these references might have, personal or otherwise. I
release all parties from all liability for any damage that may result from
furnishing this information to you.
Signed
Waiver of Liability
As a participant traveling to MAI & HCDI’s Internship Program in the
Philippines, I acknowledge I have been made aware of the daily challenges
faced while attending the program in the Philippines. In accordance with my
desire to travel to the mission field, I hereby agree to sign this waiver which
releases and discharges MAI & HCDI, its agents, servants, employees, or any
officer from all actions, claims and/or demands whatsoever. This is to include
but not be limited to all injuries to my person or property arising out of any
matters, incidents, acts, equipment failure or other circumstances, unless such
liability arises as the result of the intentional misconduct of MAI & HCDI or its
employees acting within the scope of their employment. I agree to save and
hold harmless and to fully and completely indemnify MAI & HCDI against any
and all claims, suits, and judgments related/arising out of the acts or conduct
of MAI & HCDI employees. This release indemnity agreement shall apply to all
known, unknown and/or unanticipated injuries and damages resulting from any
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cause during my participation in the CHE Internship Program.
STATEMENT OF FAITH
Every CHE Intern of Medical Ambassadors International, HCDI and Global CHE
Network subscribes to the following statement of faith:
1. We believe that the Bible, in its entirety in the original writings, is the
inspired, inerrant, infallible and authoritative Word of God.
2. We believe in one God, eternally existent in three persons: Father, Son
and Holy Spirit.
3. We believe in the deity of our Lord Jesus Christ, in His virgin birth, in His
sinless life, in His miracles, in His vicarious death and the atonement
through His shed blood, in His bodily resurrection, in His ascension to
the right hand of the Father, and in His imminent personal return in power
and glory.
4. We believe that, for the salvation of lost and sinful man, faith in the Lord
Jesus Christ provides the only grounds for justification.
5. We believe in the regenerating ministry of the Holy Spirit by whose power
the Christian is enabled to live a godly life.
6. We believe in the forgiveness of sins, the resurrection of the body and life
eternal.
7. We believe in the spiritual unity of the Church, which is the Body of
Christ, composed of all who are regenerated through faith in the Lord
Jesus Christ.
8. We believe in the reality of heaven, hell, and Satan, which gives urgency
to Christ’s command to reach the entire world with the Gospel.
Signed: __________________________
Date: __________________________
Please print name: __________________________
Location: 4048 Tully Road ~ Modesto, California 95356 ~ info@med-amb.org ~ www.med-amb.org