Summer Medical Institute - 2008
Faculty Application
 
 

  Personal Information
  Full Name:
    Gender:
  Home Address:
  City:
  State:
  Zip Code:
  Phone: ex. 123-456-7890
  Spouse's Name:
  Spouse's Occupation:  
  Email:
 


 Children names & ages:
Please list any family members you wish to bring to SMI: 
Work Information
  Employer / Practice Name:
  Office Address:
  Office City:  
  Office State:  
  Office Zip:
  Office Phone:  
  Office Contact  
  Office Fax
  Specialty
Board certification/Date:
  Medical License Number:
  Additional states where licensed/numbers  
  Are you currently involved in any malpractice litigation?  
  Church Information
Church & Denomination:
  Address:
  City  
  State
  Zip
  Pastor:
  Are you a member?
  Your Offices / Activities:

  Questions
  Please select the week you would be able to join us for the SMI: 
  Are you proficient in Spanish?     
  Briefly describe the history of your journey with God and the basis of your salvation:
 
 

Explain why you want to serve as SMI Faculty:
 
 

Briefly describe any opportunities you have had that may be relevant to your SMI participation

(i.e. health care related jobs, cross-cultural exposure, ministry experiences, etc.)
 

 
 

In addition to the informal teaching and mentoring that takes place during the week, would you be willing to teach SMI students in a workshop or small group setting? (If you are willing and if this is a need for the curriculum, we will contact you to discuss specifics.)
 
  References
 

List the names of the two people, one personal and one professional, who can be contacted for recommendations.

List their phone numbers and relationship to you.

 

 

For Your Information

1.     Thank you for your willingness to apply for SMI Faculty. All applications are due by April 1 and are subject to the approval of the SMI Board of Directors.

2.     You will be notified of a decision no later than April 15th. If accepted, you must then confirm with us the exact dates of attendance so that we can make final preparations for your arrival.

3.     You will NOT need to pursue temporary licensure for the Summer Medical Institute.


IMPORTANT, PLEASE READ THE FOLLOWING BEFORE SUBMITTING THIS FORM:

What a person believes is the foundation for both life and ministry. The following are Christian tenets to which the SMI leadership ascribes. If you disagree with any of these, please explain your differences below.

  1. The Bible is the inspired, infallible, inerrant Word of God. (2 Tim. 3:15-17)

  2. There is one God, eternally existent in three persons: Father, Son and Holy Spirit. (John 10:30)

  3. These are central truths of the Christian faith: The deity of our Lord Jesus Christ, His virgin birth, His sinless life, His miracles, His vicarious and atoning death through His shed blood, His bodily resurrection, His ascension to the right hand of the Father, and His personal return in power and glory. (Jn 1:1-5; Phil. 2:5-11, 1 Cor 15:1-6)

  4. Believing in the Person and work of Jesus Christ alone results in salvation; Jesus Christ is the only way of salvation. (Titus 3:4-7; Eph. 2:8-9; John 14:6; Acts 4:12)

  5. The Holy Spirit's present ministry and indwelling enables the Christian to live in fellowship with God. (Gal. 5:16-23; I John 1:3-4)


The commitment of the Summer Medical Institute is "to serve and not to be served." Serving in ministry means you sometimes submit to the needs of others even in areas of biblical freedom. Paul is a model of this (Romans 14 - 15:6). Serving with the SMI means you agree to the following:

  1. I am willing to set aside personal preferences, habits and schedules to fulfill the ministry of the SMI.

  2. I understand there are variations in practice and understanding of Scripture in some areas of Christian living. In serving with SMI, I will abide by the standards of the SMI in all areas including dress, entertainment, activities, etc. This includes a willing agreement to abstain from the use of alcohol, drugs, and tobacco and being sensitive to cultural, regional, church and SMI expectations and standards. See the enclosed "Policies and Procedures" page for a description of SMI expectations and standards.

  3. I will seek to provide excellent medical care to God's glory and to present Jesus Christ as Lord and Savior.

  4. If accepted to the SMI, I am willing to raise support or pay for my transportation to and from SMI.

Please state your agreement with the above, or state any differences in opinion in the box below:

 


I have read the SMI application and accept its provisions and agree to live, work and serve in accordance with them. I, the undersigned, also realize that in accepting a term of volunteer service, it is with the clear understanding that SMI does not assume responsibility for loss of my property, damage to the same, personal harm or illness that may come to those who travel with me or myself. I, for myself, my heirs, executors, administrators and assigns, in consideration of my admission to volunteer service and other good and valuable considerations, do hereby release and forever discharge SMI, the Valley Baptist Health System, the Valley Baptist Family Practice Residency from liability for any claim or demand that I or my heirs, executors, administrators or assigns might otherwise assert upon the basis of any of the foregoing.  In volunteering, I recognize that I do not become an agent or employee of SMI in rendering my services and I agree to hold SMI harmless from any claim that might arise out of any acts performed by me while serving as an SMI volunteer.
 

Please enter the last four digits of your social security number and click on submit, if you are in agreement with all of the above, or have disclosed your disagreements in the space provided above.

 
 

                

 
If you have any questions, feel free to call 956-389-2448, fax 956-389-2498, or email familypractice@valleybaptist.net.
If you had any problems submitting this form, please download the word documents and fax or mail your information to the address or number above.
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