General Hospital Questionnaire

We are grateful for your interest in World Medical Mission. Please complete this initial questionnaire and respond with the requested documents. Upon completion of this form, we will review and evaluate your submission and respond appropriately.

You can also print a pdf version of this form and return it to Samaritan's Purse, P.O. Box 3000, Boone, NC 28607-3000. Please coordinate with your World Medical Mission representative.

Date

Content Person's Information

Name

First Last Title

Telephone

Hospital Information

Hospital Name

Hospital Address

Street Address City State / Province / Region Zip Code Country

Hospital Website

Parent Organization, Denomination, or Mission Information

Name

Mailing Address

Street Address City State / Province / Region Zip Code Country

Telephone

Describe the hospital’s approach to ministry and evangelism. Also, include information about the relationship to the local church. If you need more space, please attach additional pages.

Describe the hospital facility and the services provided.

Please thoroughly read the attached files to understand the mission and beliefs of Samaritan’s Purse. We are committed to upholding these beliefs throughout the ministry for the glory of God and the protection of our beneficiaries.

Hospital Statement of Faith

Add Hospital Statement of Faith(Required)

Please attach the hospital’s Statement of Faith.

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Board Members and Key Leaders

Add List of Board Members and Key Leaders of the Hospital(Required)

Please attach a list of the board members and key leaders of the hospital.

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Financial Documents

Add Audited Financial Documents(Required)

Please attach the audited financial documents.

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Safeguarding Policy

Add Hospital Safeguarding Policy

Please attach the hospital safeguarding policy.

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If the hospital does not have a safeguarding policy, are you willing to establish one for the hospital staff?

Yes

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General Hospital Questionnaire

Content Person's Information

Hospital Information

Parent Organization, Denomination, or Mission Information

Hospital Statement of Faith

Board Members and Key Leaders

Financial Documents

Safeguarding Policy

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