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.



Content Person's Information


Hospital Information

Hospital Address

Parent Organization, Denomination, or Mission Information

Mailing Address

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

Please attach the hospital’s Statement of Faith.

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Board Members and Key Leaders

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

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Financial Documents

Please attach the audited financial documents.

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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?