International Service Opportunities Interest Form

Contact Information

Please fill out the form below to register to receive more information about international service opportunities.

Title

Last Name

Address Line 1

Address Line 2

City

State

Zip/Postal Code

Phone Number

Cell Phone

LLU Email

Are you an LLUH Employee?

Yes

Department/Unit

Job Title

Employee Status

Degrees & Certifications

Clinical License Number

Current CV/Resume

One file only.
2 MB limit.
Allowed types: pdf, doc, docx.

Languages other than English that you speak

Have you served on an international mission trip before?

Yes

Please list location of any past mission trips and objectives.

Do you have a valid Passport?

Yes

Preferred Location 1

Preferred Location 2

Preferred Location 3

What dates are you available to serve?

Questions/Comments