Internship Application

Intern Emergency Contact & Health Questionnaire
Name*

PrefixFirst NameLast Name
Date of Birth*

MonthDayYear
Date
Last 4 digits of Social Security #:*
In Case of Emergency Contact:*

PrefixFirst NameLast Name
Relationship:*
Cell Phone:*
Home Phone:
Work Phone:
Medical Outreach Ministries invites you to list below any medical conditions about which you would like for us to be aware, even though these conditions do not impair your ability to perform as an intern at the Clinic. We also invite you to list any medications that you are currently taking and the name of your primary physician.

This information would be used only if you require health assistance on an urgent or emergency basis while serving at MOM. You are not required to provide us with this information; however, any information you do provide will be treated with strict confidentiality. However, we do require that you inform us of physical limitations and any past allergic reactions to insect stings, foods, or medications.
Primary Care Physician:

PrefixFirst NameLast Name
Physician Phone Number:
Please enter a valid phone number.
Physical Limitations:
Medication, insect, or food allergies and type of reaction:
Medical Conditions:

Medication List:

	Name of Medication	Strength of Medication	How Often is Medication Taken
1
2
3
4
5
6
7
8

I attest that I am currently free of any physical or mental conditions that would impair my ability to perform the functions I agree to as an intern at MOM. I also attest that currently I am free of addiction to drugs, alcohol, or any other recreational chemical substances. I understand that I may not hold Medical Outreach Ministries responsible for any conditions that I have or have not disclosed.
Signature of Prospective Intern*

Clear
Date*

MonthDayYear
Date

Medical Outreach Ministries Guiding Principles
- In the name of Jesus Christ, MOM seeks to meet the physical, emotional, and spiritual needs of individuals who access healthcare at MOM.
- MOM never discriminates in ministering to anyone receiving care at MOM regardless of race, religion, creed, color, national origin, marital status, sex, or disability.
- MOM does not assess any fees for services, medications, or medical supplies rendered.
- MOM is committed to professional excellence as we do our work “heartily as unto the Lord, not unto men.” (Colossians 3:23).
- MOM volunteers are committed to protecting patient confidentiality.
- MOM is committed to demonstrating the love and compassion of Jesus Christ through our words, actions, and demeanor to MOM patients and to one another. These are just some of the Bible verses that guide our mission:
  - In the Words of Jesus: “…I was a stranger and you invited me in….I was sick and you looked after me….For truly I tell you, whatever you did for one of the least of these brothers and sisters of mine, you did for me. ” (From Matthew 25:35,40)
  - “Be ye kind one to another, tender-hearted, forgiving one another even as God, for Christ sake has forgiven you.” Ephesians 4:32
  - “From Him the whole body, joined and held together by every supporting ligament, grows and builds itself up in love, as each part does his work.” Ephesians 4:16
  - “Be completely humble and gentle; be patient, bearing with one another in love. Make every effort to keep the unity of the Spirit through the bond of peace.” Ephesians 4:2-3.
  - [Lord], You have been a refuge for the poor, a refuge for the needy in their distress, a shelter from the storm and a shade from the heat.” Isaiah 25:4.
  - “She opens her arms to the poor and extends her hands to the needy.” Proverbs 31:20
My initials here indicate that I agree to abide by MOM's guiding principles:*

Medical Outreach Ministries Intern Agreement
1. I will be punctual and conscientious, conduct myself with dignity, courtesy, and consideration of patients, staff, and volunteers, and endeavor to exhibit professional excellence in my work.
2. I will hold in strict confidentiality all information that I may obtain concerning patients, volunteers, and staff. I will not seek to obtain confidential information from patients unless it is part of my work assignment. I will not seek to obtain my personal health information via MOM’s computers or network.
3. I will attempt to resolve any challenges or conflicts with others in a Christ-like manner. If I need help, I will seek help from the MOM Executive Director.
4. I agree to dress in a modest business casual manner or in professional attire.
5. I will only use my first name and identify my association with MOM when leaving phone messages for patients.
6. I understand that I may be terminated at any time if my behavior is deemed inappropriate. Examples of inappropriate behavior may include breach of confidentiality, sexual harassment, use of or effects from alcohol or drugs while working at the Clinic, theft or misuse of Clinic property, unsatisfactory attitude, appearance, repeat absences without notification, and/or use of inappropriate language.
7. I will make my best effort to fulfill any assignment I accept with excellence, “as unto the Lord.”
8. I will at all times strive to uphold the Christian standards and mission of Medical Outreach Ministries while at the clinic and otherwise.
I have read and understand each of the above conditions and agree to uphold them.

Medical Outreach Ministries is not obligated to provide a placement, nor are you obligated to accept an internship position. All information provided is considered confidential.
Signature of Prospective Intern:*

Clear
Date*

MonthDayYear
Date
Should be Empty:

	Monday	Tuesday	Wednesday	Thursday	Friday
AM - 8a-12:30p
PM - 12:30p-5p

Internship Application

Intern Emergency Contact & Health Questionnaire

Medical Outreach Ministries Guiding Principles

Medical Outreach Ministries Intern Agreement