Christopher J.

Macariola
45-C J Ocampo St
Barangay Milagrosa
Project 4, Quezon City
1109 Metro Manila
Philippines

For many members of The Church of Jesus Christ of Latter-day Saints, missionary service is a significant
milestone in their lifelong spiritual growth. Church leaders desire that this sacred time of service be a joyous
and faith-building experience for every missionary, from young men and women to senior couples. With this
goal in mind, it is imperative that each missionary be appropriately prepared, worthy, and healthy.

During the interview process, your priesthood leaders will ask you the following questions. Please direct any
questions you may have to your priesthood leaders.

These questions contain links to more information from the scriptures, Preach My Gospel: A Guide to
Missionary Service, and For the Strength of Youth. Please read and study all of this information.

Interview Questions

1. Do you have faith in and a testimony of God the Eternal Father; His Son, Jesus Christ; and the Holy
Ghost?
2. Do you have a testimony that Jesus Christ is the only begotten Son of God and the Savior and Redeemer
of the world? Please share your testimony with me. How has the Atonement of Jesus Christ influenced
your life?
3. What does it mean to you to repent? Do you feel that you have fully repented of past transgressions?
4. Will you share your testimony with me that the gospel and Church of Jesus Christ has been restored
through the Prophet Joseph Smith and that [current Church President] is a prophet of God?
5. Do you have a testimony of the truthfulness of the Book of Mormon?
6. Full-time missionary service requires living gospel standards. What do you understand about the
following standards?
1. The law of chastity
2. In reference to the law of chastity, have you always lived in accordance with what has been
discussed? If not, how long ago did the transgression(s) occur? What have you done to repent?
3. Avoiding pornography
4. The law of tithing
5. The Word of Wisdom, including the use of drugs or the abuse of prescribed medications
6. Keeping the Sabbath day holy
7. Being honest in all you say and do
Have you lived in accordance with all of these standards? Are you now living in accordance with
them? Will you live in accordance with them as a full-time missionary?
7. Do you have any legal actions pending against you?
8. Have you ever committed a serious violation of criminal law regardless of whether or not you were
arrested, you were convicted, or the record was expunged?

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 9. Have you ever sexually abused a child in any way, regardless of whether or not you were charged, you
were convicted, or the record was expunged?
10. Have you ever committed any other serious transgression or misdeed that should be resolved before your
mission?
11. Do you support, affiliate with, or agree with any group or individual whose teachings or practices are
contrary to or oppose those accepted by The Church of Jesus Christ of Latter-day Saints?
12. Do you have any unpaid debts? How will these debts be paid off before your mission or managed while
you serve a mission?
13. Do you currently have or have you ever had any physical, mental, or emotional condition that would
make it difficult for you to maintain a normal missionary schedule, which requires that you work for
12–15 hours a day, including studying for 2–4 hours a day, walking or biking for up to 8–10 hours a day,
and so forth?
14. Have you ever been diagnosed with or received treatment for dyslexia or other reading disorders? If so,
are you comfortable reading the scriptures and other documents aloud? Do you believe that you could
memorize appropriate scriptures and other information with the assistance of your companion? In what
ways do you now compensate for this disorder?
15. Have you ever been diagnosed with or received treatment for a speech disorder? If so, are you
comfortable speaking in front of others? Do you feel that you have adequate tools to help you learn,
teach, and communicate?
16. Have you ever been on medication or otherwise treated for any of the following conditions: attention
deficit disorder (ADD), attention deficit hyperactivity disorder (ADHD), anxiety, depression, obsessive
compulsive disorder (OCD), or autism spectrum disorder (including Asperger’s)? If yes, please explain.
17. If you were being treated for one of these conditions and discontinued treatment, did you do so under a
doctor’s supervision? If not, why did you stop? How well have you been functioning without treatment
or medication? When was the last time you were on medication for these issues?

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 Missionary Recommendation

Christopher J. Macariola
45-C J Ocampo St
Barangay Milagrosa
Project 4, Quezon City
1109 Metro Manila
Philippines

Personal Information
First Name (middle) Last Name (Legal Name) (suffix)

Home street address

City State or province Postal code

Country District (if any) Airport

Periodically it may become necessary for the Missionary Department to communicate with you. Please
provide the following contact information.
Home phone (include area Mobile phone (indicate Can you receive SMS (text) messages
code) country and include area at this mobile number?
code) Yes No

E-mail address

All states, provinces, or countries where you have lived recently (or for extended periods)

Address where correspondence should be sent, if different from home address

City State or province Postal code

Country District (if any)

Phone (include area code) Gender

Male Female
Date of birth Confirmation date

Have you ever been

Widowed Divorced
Have you ever been arrested?
Yes No
Have you ever had a police record?
Yes No
Have you ever been convicted of a crime?
Yes No
(If yes to any of these, explain, including date of arrest, charge, and resolution.)

If any of your personal information will be changing prior to your mission, please explain. If your information changes after submitting your recommendation forms,
please notify your priesthood leader so he can call the Missionary Department in Salt Lake City, UT, USA.

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Missionary Recommendation
First Name (middle) Last Name (Legal Name) (suffix) Record number Date of birth (Age) Gender

Citizenship Information
Citizenship at birth Place of birth (City, Birth country Current country of citizenship If dual citizenship, indicate
State/Province) second country of citizenship.

Do you have an official birth certificate? Are you currently a documented citizen of your resident country? If no, indicate your current status in your
Yes No country of residence.
Yes No
Have you ever lived in a country while not properly If yes, please provide dates, locations, and circumstances of when you lived in a country while not properly
documented to be in that country? documented to be in that country.
Yes No
Have you ever stayed in a country beyond the time If yes, please provide dates, locations, and circumstances of when you stayed in a country beyond the time
allowed by your visa? allowed by your visa.
Yes No
Does your citizenship status impose restrictions on What are the nationalities of your ancestors?
traveling outside the country where you live?
Yes No
Do you have a current passport? When does your passport expire?
Yes No
Your name as it appears on your passport. (middle) Last Name (Legal Name) (suffix)
(First)

Passport Number Country of Issue

Please provide any other information you would like to have considered regarding your citizenship. If you have multiple current passports, please provide the country and
expiration date of each passport.

Identification Information
Do you have a current driver's license? Alternate Form of I.D. I.D. Type
Yes No Yes No
Your name as it appears on your (middle) Last Name (Legal Name) (suffix) ID Number
I.D. (First)

Country State or province Expiration date

Has your driver's license ever been suspended? If yes, please provide the date and reason for the suspension.
Yes No
Emergency Contact Information
Name Relationship

Address of emergency contact

City State or province Postal code

Country District (if any) Phone of emergency contact (include area code)

Do you have a parent, brother, sister, son, daughter, grandson, or granddaughter currently serving a mission?
If yes, list the names, relationships, and locations of any of these relatives who are currently serving missions.

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 Life Experience

Christopher J. Macariola
45-C J Ocampo St
Barangay Milagrosa
Project 4, Quezon City
1109 Metro Manila
Philippines
First Name (middle) Last Name (Legal Name) (suffix) Record number Date of birth (Age) Gender

Language Information
What is your primary language?

Additional languages? Please select the rating that best describes your current command of the language.
If you speak another language, select it from the 1 2 3 4 5
list below.

If you speak another language, select it from the 1 2 3 4 5

list below.

If you speak another language, select it from the 1 2 3 4 5

list below.

If you speak another language, select it from the 1 2 3 4 5

list below.

1 2 3 4 5

Key: 1 - Satisfy minimum courtesies (greetings)

2 - Converse simply about family and hobbies
3 - Converse about news and current events
4 - Comfortably handle professional situations
5 - Native
What language would you like your call letter printed in?

Indicate how interested you are in learning a language.

Very interested Interested Slightly interested Not interested
Rate how successful you feel you would be in learning a language for your mission.
Very successful Successful Slightly successful Not successful
Please express other thoughts you would like to have considered about your language skills and experience.

Education and Work Experience

How many years did you attend Did you graduate from seminary?
seminary and/or institute? Yes No
What is the highest level of education you have achieved?

Beginning with the most recent, please provide a brief summary of your skills, education, and experience at work, at home, and in the community.

Special Skills and Proficiencies N = Little to No Expertise, I = Intermediate Skill, A = Advanced Skill.
Level of expertise Skill or profession Clarifications, if any
N I A
Education Administration

Music - Choir Directing

Music - Conducting

Music - Organ

Music - Piano

School Teacher - Elementary/Secondary

Level of expertise Skill or profession Clarifications, if any

N I A
School Teacher - College

School Teacher - ESL

Social Work

Automotive Mechanic

Building Contractor

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 Building Maintenance

Building Management

Carpentry

Electrician

Painter

Plumbing

Welding

Computer - Database Administration

Computer - PC Administration

Computer - Software Engineering

Computer - Spreadsheet

Computer - Word Processing

Engineer - Chemical

Engineer - Civil

Engineer - Electrical

Engineer - Mechanical

Attorney / Judge

Communications

Family Finances

Finance - Bookkeeping

Finance - General Accounting

Finance - Tax Accounting

Office Manager

Receptionist

Sales

Level of expertise Skill or profession Clarifications, if any

N I A
Secretary

Family History Research

Farming

Gardening

Heavy-Equipment Operator

Homemaking

Landscaping

Truck Driver

Dental Hygienist

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 Elder Care

Medical - Doctor

Medical - Licensed Practitioner Nurse

Medical - Nurse Practitioner

Medical - Paramedic

Medical - Physician Assistant

Medical - Psychiatrist

Medical - Psychologist

Medical - Registered Nurse

Medical - Pharmacist

Medical - Other

Add any profession or skills that were not listed above.

Church Callings (current and former) Check all that apply.

General Authority/Area Seventy Bishop
General auxiliary presidency Bishopric counselor
Regional Representative Branch president
Mission president Branch presidency counselor
Mission presidency counselor Ward or branch executive secretary
Temple president Ward or branch clerk
Temple presidency counselor High priests group leader
Temple recorder High priests group assistant
Temple sealer Elders quorum president
Temple ordinance worker Elders quorum presidency counselor
Stake president Ward mission leader
Stake presidency counselor Ward or stake missionary
Stake mission president Ward or branch Young Men president
Patriarch Ward or branch Young Men presidency counselor
High council Scout leader
District president Ward or branch Sunday School presidency
Stake or district executive secretary Sunday School teacher
Stake or district clerk Teacher in auxiliary organization
District presidency counselor Seminary or institute teacher
Stake or district Young Men president Family history center
Stake or district Young Men presidency counselor Family history specialist
Stake or district Sunday School presidency FamilySearch indexing
Please list the temples where you have served in a calling or as an ordinance worker.

Please tell us about any other Church service that you would like to have considered.

Prior Mission Experience

Have you served other full-time missions?
Yes No
Beginning with the most recent, please tell us about each of your prior missions. To add a mission, click Add Another. To remove a mission, click Remove next to the
row to be removed.
From To In which state or country did you serve? What type of mission was it?

Please provide any additional information about previous full-time mission experiences that you would like to have considered.

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Life Experience
First Name (middle) Last Name (Legal Name) (suffix) Record number Date of birth (Age) Gender

Military Information
Do you have current or previous military experience? Name of military organization or branch of military service
Yes No
Are you retired military?
Yes No
Are you a current member of a military reserve unit? Name of reserve organization
Yes No
Name of commanding officer

Unit mailing address City

Country

State or province Postal code

Please list any additional details about your military service that you would like to be considered.

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 Assignment Preferences

Christopher J. Macariola
45-C J Ocampo St
Barangay Milagrosa
Project 4, Quezon City
1109 Metro Manila
Philippines
First Name (middle) Last Name (Legal Name) (suffix) Record number Date of birth (Age) Gender

Finances
Total to be paid per month Indicate how much money (in your local currency) will be contributed per month in support of your mission from the sources
below. Enter single combined amount for a couple in “Self.”
Local currency
Self (per month) Family (per month) Ward or branch (per month) Other (per month) Total to be paid per month

Of the above total amount, how much will you commit to pay per month
toward your housing expenses?
Please let us know anything else you would like to have considered about your finances.

Timing
Mission calls vary in length. Please indicate the maximum amount of time you can Date available to serve
serve, understanding that you may be called to serve for a shorter duration.
23 months 18 months 12 months 6 months
Do you have a reverse mortgage? (Please note that the conditions of many reverse mortgages restrict how long you may be out of your home. For details, contact your
mortgage lender.)
Yes No
Please tell us about any limitations or special circumstances related to your term of service.

Location
Where would you prefer to serve?
In own country Outside own country No preference
Senior missionaries from the United States and Canada who serve a mission within the United States or Canada are expected to take their car to their mission. If you are
asked to serve in the United States or Canada, will you be able to take your car to your mission?
Yes No
In the space below, please address the following:

Limitations: Provide clarifications or explanations regarding your answer above.

Requests: If someone has requested that you serve in a specific mission, note the name of the individual and the mission.

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 Unit Information for Missionary Candidate

Christopher J. Macariola
45-C J Ocampo St
Barangay Milagrosa
Project 4, Quezon City
1109 Metro Manila
Philippines
First Name (middle) Last Name (Legal Name) (suffix) Record number Date of birth (Age) Gender

Home Unit Information

Home ward or branch Unit number Home stake or mission Unit number

Name of home bishop or branch president Name of home stake or mission president

Mailing address (including country) Mailing address (including country)

Home phone (area code) Work phone (area code) Cell phone (area code) Home phone (area code) WorkPhoneLabel Cell phone (area code)

E-mail address Fax E-mail address Fax

Submitting Unit Information (If other than home unit)

Ward or branch Unit number Stake or mission Unit number

Name of bishop or branch president Name of stake or mission president

Mailing address (including country) Mailing address (including country)

Home phone (area code) Work phone (area code) Cell phone (area code) Home phone (area code) Work phone (area code) Cell phone (area code)

E-mail address Fax E-mail address Fax

Funding Unit Information (If other than home unit)

Ward or branch Unit number Stake or mission Unit number

Name of bishop or branch president Name of stake or mission president

Mailing address (including country) Mailing address (including country)

Home phone (area code) Work phone (area code) Cell phone (area code) Home phone (area code) Work phone (area code) Cell phone (area code)

E-mail address Fax E-mail address Fax

Membership Unit Information (If other than home unit)

Ward or branch Unit number Stake or mission Unit number

Name of bishop or branch president Name of stake or mission president

Mailing address (including country) Mailing address (including country)

Home phone (area code) Work phone (area code) Cell phone (area code) Home phone (area code) Work phone (area code) Cell phone (area code)

E-mail address Fax E-mail address Fax

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 Health Insurance Information of Prospective Missionary

Christopher J. Macariola
45-C J Ocampo St
Barangay Milagrosa
Project 4, Quezon City
1109 Metro Manila
Philippines
First Name (middle) Last Name (Legal Name) (suffix) Record number Date of birth (Age) Gender

Do you have Medicare (government sponsored health care in the United States)? Do you have other government sponsored health care?
Yes No Yes No
Do you have a private medical insurance provider? Will you be covered by a group or individual health insurance plan while serving your mission?
Yes No Yes No
Will you have coverage from another insurance company?
Yes No
Other Insurance Considerations
Please let us know anything else that may be important concerning your health insurance.

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 Personal Health History of Missionary Candidate

Christopher J. Macariola
45-C J Ocampo St
Barangay Milagrosa
Project 4, Quezon City
1109 Metro Manila
Philippines
First Name (middle) Last Name (Legal Name) (suffix) Record number Date of birth (Age) Gender

Please answer all of the following questions. Be honest with yourself, your physician, and the Lord. Major difficulties may result if this
information is not complete and accurate. Please do not withhold or deny any medical information.

Key: Current = is currently occurring; Previous = occurred previously, but is now resolved; Never = has never occurred
Current Previous Never 1.1 Injury to head

Current Previous Never 1.2 Headaches (migraine, tension, or other serious headaches)

Current Previous Never 1.3 Seizures (convulsions, epilepsy) multiple sclerosis, or Parkinson's disease

Current Previous Never 1.4 Dizziness or fainting

Current Previous Never 1.5 Stroke

Current Previous Never 1.6 Loss of balance sense

Current Previous Never 1.7 Memory loss, dementia, or speech or learning difficulties

Current Previous Never 2.1 Visual impairment, not correctable

Current Previous Never 2.2 Glaucoma, cataracts, macular degeneration, or retinal detachment

Current Previous Never 2.3 Major hearing loss not corrected by hearing aid

Current Previous Never 2.4 Sinus problems

Current Previous Never 2.5 Sleep apnea

Current Previous Never 2.6 Mouth/dental problems needing correction

Yes No 2.7 Do you wear full-mouth dentures?

Current Previous Never 3.1 Asthma

Current Previous Never 3.2 Emphysema or chronic lung disease

Current Previous Never 3.3 Tuberculosis, chronic cough, coughing up blood, positive PPD skin test, or unexplained fatigue or fever

Current Previous Never 3.4 Pneumonia

Current Previous Never 3.5 Collapsed lung (pneumothorax)

Current Previous Never 3.6 Pulmonary embolism (blood clot to lungs)

Current Previous Never 4.1 Arthritis or joint pain

Current Previous Never 4.2 Joint replacement or other joint operation

Current Previous Never 4.3 Fractures

Current Previous Never 4.4 Osteoporosis

Current Previous Never 4.5 Loss of limb or major limb deformity

Current Previous Never 4.6 Paralysis, muscle weakness, or numbness

Current Previous Never 4.7 Difficulty walking or climbing stairs

Current Previous Never 4.8 Require cane, crutch, walker, wheelchair, or other mobility device

Current Previous Never 5.1 Degenerative disk disease

Current Previous Never 5.2 Chronic neck or back pain

Current Previous Never 5.3 Operation on spine

Current Previous Never 5.4 Scoliosis or spinal curvature

Current Previous Never 6.1 Problems with being overweight

Current Previous Never 7.1 Acne, eczema, or other skin condition

Current Previous Never 8.1 Hypertension or high blood pressure

Current Previous Never 8.2 Coronary artery disease (angina chest pain, prior heart attack, angiogram, stent, or bypass grafts)

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Current Previous Never 8.3 Heart valve disease, repair, or replacement

Current Previous Never 8.4 Irregular heart rhythm, medically treated, ablation procedure, pacemaker, or internal defibrillator

Current Previous Never 8.5 Heart failure, chronic

Current Previous Never 8.6 Congenital heart condition

Current Previous Never 9.1 Acid reflux or ulcers

Current Previous Never 9.2 Irritable bowel, pain, constipation, or chronic diarrhea

Current Previous Never 9.3 Ulcerative colitis or Crohn's disease

Current Previous Never 9.4 Diverticulosis, diverticulitis of colon

Current Previous Never 9.5 Rectal bleeding

Current Previous Never 9.6 Gastritis

Current Previous Never 9.7 Hernia

Current Previous Never 10.1 Gall stones or gall bladder disease

Current Previous Never 10.2 Hepatitis, chronic type B or C

Current Previous Never 10.3 Cirrhosis

Current Previous Never 11.1 Kidney stones

Current Previous Never 11.2 Kidney failure/dialysis

Current Previous Never 11.3 Kidney and bladder infections

Current Previous Never 11.4 Frequent or difficult urination

Current Previous Never 11.5 Urine incontinence

Current Previous Never Male: varicocele, prostate enlarged, operation on prostate gland (not for cancer), prostate infection, or known sexually
12.1
transmitted disease
Current Previous Never 13.1 Diabetes mellitus type I or II

Current Previous Never 13.2 Thyroid function increased or decreased, gland enlarged or nodules, or thyroid gland removal

Current Previous Never 13.3 Adrenal

Current Previous Never 13.4 Other endocrine issues

Current Previous Never 14.1 Leukemia

Current Previous Never 14.2 Anemia

Current Previous Never 14.3 Clotting abnormality (prolonged bleeding, excessive clotting, or deep vein thrombosis)

Current Previous Never 14.4 Taking anticoagulant medications

Current Previous Never 14.5 Peripheral vascular disease or pain in legs while walking

Current Previous Never 14.6 Aneurysm (enlargement of artery)

Current Previous Never 15.1 Tumor (non-malignant)

Current Previous Never 15.2 Malignant cancer of any organ

Current Previous Never 15.3 Skin cancer or melanoma

Current Previous Never 15.4 Screening tests for cancer; lung, colon, breast, uterus, or prostate

Current Previous Never 16.1 Allergies requiring shots or other allergy prescription medications

Current Previous Never 16.2 Food allergy or intolerance

Current Previous Never 16.3 Lupus erythematosus, scleroderma, or rheumatoid arthritis

Current Previous Never 16.4 Organ transplant

Current Previous Never 17.1 Depression (including suicidal plans or attempts)

Current Previous Never 17.2 Anxiety

Current Previous Never 17.3 Bipolar disorder, schizophrenia, obsessive compulsive disorder, psychosis, or eating disorder (bulimia, anorexia)

Current Previous Never 17.4 Insomnia

Current Previous Never 18.1 Chronic fatigue or pain syndrome, Fibromyalgia syndrome

Current Previous Never 19.1 Any hospitalization, disease, injury, or regularly required health care not previously listed

Current Previous Never 20.1 Adverse reaction to medication

Yes No Are you currently taking any prescription medications, herbal medications, alternative treatments, or diet
20.2
supplements?

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© 2022 by Intellectual Reserve, Inc. All rights reserved.
All missionaries, including those serving in their resident country, are required to receive immunization for tetanus/diphtheria and hepatitis A and B . In addition,
missionaries born after 1957 also require immunizations for measles/mumps/rubella (MMR 1 and 2) and polio. Although the immunizations are not required before
completing this form, they should be completed as soon as possible before entering the MTC. While not required, senior missionaries are also encouraged to be
vaccinated against pneumonia and shingles.

Please select the full date you received each of the following immunizations. If you do not have record of or cannot recall the exact date, provide your best estimate. If you
have not received an immunization, leave the date blank.
21.1 Tetanus/diphtheria/pertussis #1
21.2 Tetanus/Diphtheria/Pertussis (TDAP)
21.3 MMR1
21.4 MMR2
21.5 Polio
21.6 Hepatitis A #1
21.7 #2
21.8 AND hepatitis B #1
21.9 #2
21.10 #3
21.11 OR combined hepatitis A and B #1
21.12 #2
21.13 #3
21.14 Influenza
21.15 COVID-19 Pfizer & BioNTech #1
21.16 #2
21.17 COVID-19 Moderna #1
21.18 #2
21.19 COVID-19 CureVac #1
21.20 #2
21.21 COVID-19 Sputnik V #1
21.22 #2
21.23 COVID-19 Oxford-Astrozeneca #1
21.24 #2
21.23 COVID-19 Covaxin #1
21.24 #2
21.23 COVID-19 Sinovac #1
21.24 #2
21.26 COVID-19 BBIBP #1
21.24 #2
21.25 COVID-19 CanSinoBIO
21.26 COVID-19 Johnson & Johnson
Yes No 21.27 If necessary, will you receive additional vaccinations (including the COVID-19 vaccine)?
Declaration and Authorization by Prospective Missionary
I declare that the statements made in the Personal Health History of Prospective Missionary are a complete and honest report of my
health history. No personal health information has been withheld or misrepresented.

I hereby authorize The Church of Jesus Christ of Latter-day Saints to collect, process, and transfer to other countries for Church
purposes my personal data, including sensitive data, in accordance with the Church's Global Privacy Notice.
Prospective missionary's signature Date

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 Physician's Evaluation for Senior Prospective Missionary

Christopher J. Macariola
45-C J Ocampo St
Barangay Milagrosa
Project 4, Quezon City
1109 Metro Manila
Philippines
First Name (middle) Last Name (Legal Name) (suffix) Record number Date of birth (Age) Gender

Instructions for Physicians Evaluating Missionary Candidates

General Instructions: 8. In addition to the examining health care provider, the
1. The Physician's Evaluation may be completed by a: medical prospective missionary must also sign the completed form.
doctor (MD), osteopathic doctor (DO), physician assistant (PA), 9. Return this completed and signed evaluation form, any needed
or advanced nurse practitioner (NP). (These are referred to as attachments, and the prospective missionary's signed Health
"health care providers".) An examination by any other History form to the prospective missionary.
practitioner is not acceptable.
2. The following tests are recommended for all missionaries: To the Prospective Missionary:
a. A colonoscopy if over 50 years old; 1. Take this Physician's Evaluation form and your signed Health
b. A mammogram for sisters if over 40 years old; History form to your medical examination. Your health care
c. A stress test is required if there are significant risks for orprovider will complete the evaluation form and return both forms
symptoms of coronary artery disease or if there is known history to you.
of coronary artery disease. 2. If a surgery or procedure has occurred within approximately the
Note: Those who do not complete these tests as indicated will last 6 months, you must provide an explanation of the outcome
not be considered for foreign missions and will serve in the and current recovery status from the performing health care
country where they reside. provider.
3. If you are taking prescription medication for any chronic
problem or medical or emotional condition, continue taking the
To the Examining Health Care Provider: medication unless advised by your health care provider.
1. To be valid, the examination associated with the information 4. All anticipated procedures and surgeries must be completed
on this form should have been done within the last year. prior to submitting your recommendation forms.
2. The prospective missionary's Health History form should be 5. You must sign the Physician's Evaluation form to allow the form
reviewed during the examination to assure evaluation of to be used as part of your missionary recommendation.
self-reported conditions. 6. Give the completed and signed Physician's Evaluation form,
3. Medical conditions should be stabilized prior to attesting to the any needed attachments, and your Health History form to your
prospective missionary's medical status. This includes new bishop or branch president.
conditions diagnosed during the examination, as well as known
conditions requiring altered medication regimens and care. To the Priesthood Leader:
4. When a recent major illness, operation, injury, hospitalization, 1. Review the entire form to ensure that all applicable questions
or prolonged treatment is reported, please attach a summary have been answered.
report of the incident from the professional who provided 2. Scan and attach all documents provided by the health care
treatment. provider.
5. If the prospective missionary is referred to specialty care, 3. All anticipated procedures and surgeries must be completed
please attach that specialist's evaluation and conclusions. prior to submitting the recommendation forms.
6. Required laboratory tests: 4. Ensure that the form has been signed and dated by both the
• Hemoglobin or Hematocrit health care provider and the prospective missionary.
• Dipstick Urine: blood, protein, sugar 5. The original, signed evaluation form and Health History form
• Tuberculosis screening should be kept in a secured file at the stake until the missionary
7. Please mark the appropriate box in the "Assessment of has been released for one year, at which time the forms should be
Functional Ability" at the end of the evaluation to indicate the burned or shredded.
prospective missionary's overall ability to function.

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Physician's Health Evaluation for Prospective Missionary
First Name (middle) Last Name (Legal Name) (suffix) Record number Date of birth (Age) Gender

To the physician: Please type, print, or write legibly in black ink when completing this form. Attach additional information if
necessary. Return this completed and signed evaluation form, any needed attachments, and the prospective missionary's signed
Health History form to the prospective missionary. Your thorough evaluation and completion of all requested forms, information, and
recommendations will be greatly appreciated.
Height (in inches or centimeters) Weight (in pounds or kilograms) Blood pressure Pulse Vision (with corrective lenses, if required)
in. cm. lbs. kg. / Left Right
General appearance Attention: If a test result is abnormal, please refer to item number, give details of the repeat or
Normal Abnormal additional testing, and describe treatment or other consultation if needed.
Skin
Normal Abnormal
Eyes
Normal Abnormal
Ears/balance (audiogram if necessary)
Normal Abnormal
Nose, throat, neck, and thyroid
Normal Abnormal
Chest and lungs
Normal Abnormal
Heart and blood vessels (murmurs)
Normal Abnormal
Abdomen (masses, liver, and spleen)
Normal Abnormal
Genitalia, varicocele, hernia, and pilonidal area
Normal Abnormal
Prostate (if recommended by clinician)
Normal Abnormal
Back (history of pain, disability, treatment; also pilonidal disease)
Normal Abnormal
Upper extremities
Normal Abnormal
Lower extremities
Normal Abnormal
Neurological system
Normal Abnormal
(Women only) breasts
Normal Abnormal Not indicated
(Women only) Reproductive organs: pelvic examination required
only if symptomatic, previously sexually active, or over age 40
(including PAP test completed within last 2 years).
Normal Abnormal

© 2022 by Intellectual Reserve, Inc. All rights reserved.

Physician's Evaluation for Senior Prospective Missionary
First Name (middle) Last Name (Legal Name) (suffix) Record number Date of birth (Age) Gender

17. Urinalysis (not required for young missionaries; enter actual test results or “not Attention: If a test result is abnormal, please refer to item number, give details of
done”) the repeat or additional testing, and describe treatment or other consultation if
• Dipstick—blood (required) needed.
• Dipstick—protein (required)
• Dipstick—sugar (required)
• Microscopic (if dipstick abnormal)
18. Hemoglobin or hematocrit (check the type and enter the test result)
Hematocrit (%) Hemoglobin (g/dl)

PSA testing (if indicated)

Mammogram (within last year for females over 40)

19. Tuberculosis (TB) screening:

TB exposure risk: Has the prospective missionary been exposed to any person
with active tuberculosis, or lived or worked in a circumstance of high tuberculosis
incidence such as a country, health care facility, shelter, jail, or reservation?
Yes No
Tuberculosis screening (PPD skin test or interferon test or X-ray) is required for
all prospective missionaries, including those who had BCG vaccine and/or those
who are known to be skin-test positive. Where PPD or interferon are not
available, a chest X-ray is required.

A chest X-ray is also required in any of the following circumstances:

1. The prospective missionary has a low TB risk (answered NO to TB exposure
risk above) and the PPD is 15mm or greater.
2. The prospective missionary has a high TB risk (answered YES to TB
exposure risk above) and has a PPD of 10mm or greater.
3. The interferon test is positive.
Screening results:
PPD millimeters of induration
mm PPD not done
Interferon results
Negative Positive Not Done
Chest X-ray results
Normal Abnormal Not Done
TB comments / follow-up plan (required if X-ray is abnormal)

Is the prospective missionary currently taking any medication or is there any other
factor that might impair their ability to drive? (If yes, explain.)
Yes No
27. Exercise Electrocardiography (Stress Test):
Required if the prospective missionary has ever had coronary artery bypass
surgery, coronary angioplasty, or coronary stent placement.
Recommended for those with three or more of the following risk factors:
Prospective missionary is a male over 50 years old.
Prospective missionary has hypertension.
Prospective missionary has hypercholesterolemia.
Prospective missionary has diabetes mellitus, is obese, or has metabolic
syndrome.
Prospective missionary has a family history of early onset coronary artery
disease.
Prospective missionary has had chest pain consistent with angina
pectoris.
Date of Test Normal Abnormal

© 2022 by Intellectual Reserve, Inc. All rights reserved.

Physician's Evaluation for Senior Prospective Missionary
First Name (middle) Last Name (Legal Name) (suffix) Record number Date of birth (Age) Gender

28. Diabetes Mellitus: If the prospective missionary has diabetes mellitus, the following items are Attention: If a test result is abnormal, please refer to item number,
required: give details of the repeat or additional testing, and describe
28.1 Hemoglobin A1C treatment or other consultation if needed.
Hemoglobin
A1C Lab
results:
28.2 Retinal examination by an ophthalmologist
Normal Abnormal
28.3 Kidney function
Creatinine:
Spot urine, albumin/creatinine ratio (ACR) in mg/mmol: mg/mmol
28.4 Lipid Profile
Fasting Fasting
HDL:
cholesterol: triglyceride:
28.5 Diabetic foot examination for neurological and vascular abnormalities
Normal Abnormal
28.6 Exercise electrocardiography
Normal Abnormal

Assessment of Functional Ability and Need for Medications or Medical Care Based on a review of the prospective missionary's history, your personal interview, a
physical examination, and a review of laboratory findings, indicate the prospective missionary's ability to function at various levels of activity as a missionary below.
Level A: No limitation Level B: Slight limitation Level C: Moderate limitation Level D: Marked limitation Level E: Not appropriate
(No limitation of (Slight limitation of (Moderate limitation of (Marked limitation of (Conditions exist that
activity in lifting, activity; slight decrease activity; moderate decrease of activity or has special preclude full-time
carrying, walking 6 of function or stamina, function or stamina; requires requirements, such as missionary service.)
or more miles per such as problems with limited walking (0-3 miles per specific climate, use of
day, or spending 12 walking (limited to 3-6 day) or sedentary work.) wheelchair, frequent rest
to 16 hours per day miles per day) or with periods, special medical
in missionary extensive standing.) needs, or medical visits.)
activity.)
Based on your review of this candidate's history, physical examination, laboratory tests, and consultations, please answer the following questions:

Does the missionary have any chronic physical or mental condition that will need follow-up care or continuing medication during his/her mission?
Yes No

If yes, what is the condition? by what kind of physician and how often should the missionary be seen? What medications are required? Provide your answers in the
comments box below.
Comments

Physician's signature Name of physician Date of exam

MD DO NP
Physician's office address City State or province

Country Postal code District (if any)

Office phone (with area code) E-mail address (if available)

Authorization to Release Information

I authorize the examining physician to release the information contained in the Personal Health History of Missionary Candidate and the Physician's Health Evaluation of
Missionary Candidate to my bishop or branch president and the Missionary Department of The Church of Jesus Christ of Latter-day Saints. I am aware that the
information will be screened by physicians. I am aware that the information may be used in assessing assignments as part of my missionary call. I hereby release the
examining physician from all legal liabilities that may arise from the release or use of the information by The Church of Jesus Christ of Latter-day Saints or its agents.
Missionary candidate's signature Date of signature

Witness's signature Date of signature

© 2022 by Intellectual Reserve, Inc. All rights reserved.

 Dentist's Evaluation for Senior Prospective Missionary

Christopher J. Macariola
45-C J Ocampo St
Barangay Milagrosa
Project 4, Quezon City
1109 Metro Manila
Philippines
First Name (middle) Last Name (Legal Name) (suffix) Record number Date of birth (Age) Gender

General instructions:
1. The Dentist's Evaluation is valid for one year from the date the form is signed by
the dentist. 3. Take this Dentist's Evaluation form to your dental examination.
2. Active orthodontic treatment is defined as any of the following: 4. When all required dental care has been completed or scheduled, your dentist will
a. Bonded or banded braces on the teeth. return the completed form to you.
b. Invisalign treatment trays. 5. You must sign the Dentist's Evaluation form to allow the form to be used as part of
c. Removable appliances requiring periodic adjustments. your missionary recommendation.
Note: Wearing a final retainer appliance after active orthodontic treatment is 6. Give the completed form to your bishop or branch president.
completed is not considered active treatment.
To the examining dentist: To the priesthood leader:
As you evaluate this prospective missionary's dental condition, please be aware 1. Scheduled dental care and active orthodontic treatment must be completed before
that he/she might be assigned to serve for up to two years in an area of the world a prospective missionary begins missionary service.
with limited or inadequate professional dental care. 2. All required dental treatment must be completed or scheduled before submitting
1. If the prospective missionary wears full-mouth dentures, please evaluate their the recommendation.
oral health and indicate their status in the comments section. In this situation, the 3. Ensure that the form is complete and has been signed and dated by both the
remaining questions on the form do not need to be answered. examining dentist and the prospective missionary. (See instruction #1 to the
2. When you are satisfied that all treatment has been completed or scheduled, prospective missionary for an exception to this rule.)
return the completed and signed evaluation form to the prospective missionary. 4. The original, signed evaluation form should be kept in a secured file at the stake
until the missionary has been released for one year, at which time it should be
burned or shredded.

First Name (middle) Last Name (Legal Name) (suffix) Record number Date of birth (Age) Gender

Dental Evaluation
Has the prospective missionary had a complete oral examination with bitewing radiographs within the last six months? Yes No

2. Not applicable for seniors

3. Not applicable for seniors

Has all dental decay and gum infection been resolved? Yes No

Is the prospective missionary currently undergoing active orthodontic treatment (such as braces)? Yes No

Given that this individual might not have access to professional dental care (including exams and cleanings) for 18–24 Yes No
months, do you believe that he or she will be free of dental problems for this period if proper oral hygiene is practiced?
Comments:

Dentist’s signature (Please complete all dental work before signing this form) Name of dentist Date completed or evaluated

Dentist's office address City State or province

Country Postal code District (if any)

Office phone (with area code) E-mail address (if available)

Authorization to Release Information

I authorize the examining dentist to release the information contained in this dental evaluation to my bishop or branch president and the Missionary Department of The
Church of Jesus Christ of Latter-day Saints. I am aware that the information will be screened by dentists. I am aware that the information may be used in assessing
assignments as part of my missionary call. I hereby release the examining dentist from all legal liabilities that may arise from the release or use of the information by The
Church of Jesus Christ of Latter-day Saints or its agents.
Missionary candidate's signature Date

Witness's signature Date

© 2022 by Intellectual Reserve, Inc. All rights reserved.

 Privacy Agreements

Christopher J. Macariola
45-C J Ocampo St
Barangay Milagrosa
Project 4, Quezon City
1109 Metro Manila
Philippines
First Name (middle) Last Name (Legal Name) (suffix) Record number Date of birth (Age) Gender

Authorizations, Notices, and Releases of Information

I hereby authorize The Church of Jesus Christ of Latter-day Saints, its officers, leaders, employees, affiliated entities, and departments, including (as applicable) my
mission leadership couple and my home unit priesthood leaders, such as the bishop and stake president, together with clerks and service mission leaders or coordinators
who may assist my local priesthood leaders (collectively the "Church"), to process my personal and sensitive data for purposes relating to missionary service in the
Church in accordance with the Church's Global Privacy Notice and these Privacy Agreements. (My mission leadership couple refers to the mission president and
companion, historic site president and companion, temple president and matron, and/or visitor center director and companion who oversee me, depending on my mission
assignment.).

This authorization includes the following understandings and consents:

1. The Church will have access to my personal and sensitive data, including sensitive data relating to my ethnic origin, religious
beliefs, physical and emotional health, and any criminal history, for the purposes of evaluating my missionary
recommendation, determining my missionary assignment if my recommendation is accepted, overseeing my mission, and
responding to emergencies and other circumstances that might affect my missionary service. I consent that the Church may
process my personal and sensitive data for these purposes.

2. I have informed my parents and/or caregivers that I will include some of their personal data in my missionary
recommendation.

3. My Bishop and Stake President (or Branch President, District President and Mission President, as the case may be) will
provide evaluations of my qualifications to serve as a missionary. I agree that these evaluations are related to determining
my worthiness and capacity to serve as a missionary. I understand that these evaluations are strictly confidential and I
hereby waive any right of access to these evaluations.

4. The provision of my personal data is necessary in order for the Church to process my missionary recommendation.

5. I authorize the transfer of my personal data, including sensitive data relating to my ethnic origin, religious beliefs, physical
and emotional health, and any criminal history, to Church headquarters in the State of Utah, United States of America and to
other countries with less stringent data protection laws than the country in which I reside. I understand and acknowledge that
the transfer of this information is necessary for the Church to evaluate my recommendation to serve the Church as a
missionary.

6. With the exception of ecclesiastical leaders' evaluations, I may access, upon my written request, the personal data I have
provided in connection with this missionary recommendation and I may rectify any erroneous data.

7. I understand that the Church may have occasion to film or record me in connection with my missionary service. The Church
also may have access to images and videos of me that I post on social media or on other public websites or apps while
serving as a missionary. I authorize the Church to record or copy my name, voice, image, likeness, and performance in
connection with my missionary service, and to use such recordings and copies in any way and for any purpose related to the
Church's missionary activities (including to reproduce, distribute, publish, adapt, edit, display, translate, summarize, create
derivative works from, and sublicense). I waive any right to inspect, approve, or be compensated for such recording and use.

8. If I drive or am a passenger in a Church vehicle, I authorize the Church to record telematics data, such as who is traveling,
location, movements, speed, idle time, length of stops, miles driven, fuel usage, maintenance, seat belt use, acceleration,
deceleration, rapid starts, hard turns, and accidents. Some vehicles may also record video. This data may be used as part of
the Church’s Driver Accountability Program to promote safety, respond to incidents, and protect vehicles, occupants, and
others.

9. I authorize the Church to share information about my missionary service at its discretion with governmental or similar
organizations for limited statistical or reporting purposes. I also authorize the Church to verify my mission assignment(s) and
my dates of service when contacted by third parties for post-mission employment verification, such as when the government
or a private employer asks to verify when/where I served as a part of a background check.

10. If I am called to a service mission, I authorize the Church to share my personal and sensitive data (including my contact
information, information pertaining to my physical and emotional health and capabilities, and information relating to the
performance of my missionary service) with any charities or civic organizations where I am assigned to volunteer as
reasonably necessary for the purpose of coordinating and managing my missionary service.

11. Upon completion of my mission, my general contact information may be included in a returned missionary directory

© 2022 by Intellectual Reserve, Inc. All rights reserved.

 11.
accessible to my former mission leadership couple(s) for the purpose of keeping us connected. I understand that I can opt
out or limit how my contact information is shared by modifying my profile preferences as described in the Church's Global
Privacy Notice.

12. I understand that, while the Church tries hard to protect the confidentiality of my data, when I authorize my data to be shared
under these Privacy Agreements the data may be shared via telephone, email, text message or other means that potentially
could be intercepted or read by a third party.

13. The Church will retain my personal data during my mission. Although some data will be destroyed after completion of my
mission, other data may be retained indefinitely as part of the historical or other records of the Church. Some data (such as
vehicle telematics information) will be anonymized after my personal data is no longer needed. I authorize the Church to use
and retain my data in its discretion.

14. Should I have questions concerning the protection of my personal data or the security of personal data processed by the
Church, I have been advised that I may communicate my questions to the Church's representative for data privacy at
[email protected].

Missionary Funds

I understand that all donations to the Church's missionary funds become the property of the Church to be used at the Church's sole discretion in its missionary program
and are not refundable.

Electronic Devices
The Church allows the use of technology to help me fulfill my missionary purpose. The Church may provide a device to me or I may be required to purchase a
Church-approved device, but regardless of ownership I recognize that using technology is a privilege that can be revoked. I hereby accept the responsibility to use
technology only in ways that are consistent with my missionary calling and not in any way that is obscene, defamatory, illegal, or hateful or that infringes the rights of
others. I understand that as a missionary I may have access to personal and private information of others, including non-members and members of the Church. I agree to
keep confidential all personal information contained in systems and devices to which I may have access, and commit not to share it with anyone who is not authorized.

To ensure I am using the device appropriately, I will allow the Church to inspect and monitor my use at any time. This may include: (i) tracking the movement and the
location of devices provided to me; (ii) monitoring my communications, internet searches, or downloads; (iii) remotely wiping the device of all data; or (iv) locking the
device to prevent access by unauthorized persons. I understand that if a device is wiped I may permanently lose all data that has not been backed up. I will have no
expectation of privacy when using computers or electronic devices as a missionary. I will obey all mission rules and instructions regarding use of technology, including the
use of security precautions like passwords and encryption. I agree to report a lost or stolen device to the Church immediately, to install and use only authorized software
and applications, and to abide by the terms of any licence agreements to which Church devices may be subject.

Insurance, Liability, and Medical Expense Acknowledgement

Handbook 1: Stake Presidents and Bishops indicates that all missionaries are strongly encouraged to maintain their existing medical insurance during their missions. This
conserves Church funds and helps missionaries avoid having to prove insurability after their missions. Maintaining coverage helps provide protection for past chronic or
congenital problems and post-mission medical needs. This directive is consistent with the principles of self-reliance and self-sufficiency.

Couples and single sisters ages 40 and over are responsible for their own health care expenses and must have health insurance adequate for their mission assignments.
If the insurance coverage of those living away from home is not adequate for their assignment, Deseret Mutual will send them information on additional insurance that
they may purchase. Missionaries who need additional coverage but do not enroll in the DMBA plan must provide proof of adequate coverage before their service begins.

Acknowledgement:

I understand that if I am called to a service mission, I am solely responsible for all of my medical, dental, and liability expenses.

For proselyting missionaries, I understand that if I become sick or injured during my mission, the Church may provide initial payments for my medical expenses except for
preexisting conditions. Payments in the United States will be made through Missionary Medical, a Department of Deseret Mutual Benefit Administrators (DMBA), a
not-for-profit Church affiliated entity. Payments outside the United States will be made through Aetna International and its network partners.

These payments are made from the general funds of the Church and are gratuitous and voluntary in nature. Payments are not made from a Church insurance policy and
are not intended to replace my personal health insurance.

Likewise, if I am involved in an accident while driving a Church-owned vehicle for which the Church carries insurance, but the damages attributable to me exceed the
coverage limits, the Church may seek contribution from any personal or family liability insurance policy available to me, including but not limited to automobile,
homeowner's, or general liability policies.

In either case, I understand that claims will be filed with my insurance carrier. I agree to support all recovery efforts (including assisting in claims filing and reimbursement
procedures) in the event the Church makes initial payment for medical expenses. I agree to support efforts by Missionary Medical to coordinate care directly with my
parents (when authorized for disclosure), healthcare providers, and my insurance carrier.

I understand that if I am involved in an accident that the Church neither encourages nor discourages legal action from potentially liable or responsible third parties. I agree
to reimburse the Church for expenses paid on my behalf in the event a settlement is reached or when a liable party makes payments.

I Accept I Do Not Accept

© 2022 by Intellectual Reserve, Inc. All rights reserved.

Privacy Agreements
First Name (middle) Last Name (Legal Name) (suffix) Record number Date of birth (Age) Gender

Medical Privacy Notice

Service missionaries are responsible for their own healthcare and for all health and dental insurance and expenses. This Medical Privacy Notice will apply only if I am
called to serve a proselyting mission. For more information about how the Church protects the health information of service missionaries, please see the Church's Global
Data Privacy Policy.

Deseret Mutual Benefit Administrators (DMBA), through its Missionary Medical Department, helps to coordinate and administer missionary health care for proselyting
missionaries. DMBA is a not-for-profit Church-affiliated entity that has been assigned by the Church's Missionary Department. The United States government has enacted
privacy laws and regulations with which DMBA must comply. One of the requirements is to provide you with a Notice of Privacy Practices explaining how your health
information will be used and disclosed.
1. Understanding Your Health Record/Information
Each time you visit a hospital, physician, or other health-care provider, a record of your visit is made. Typically, this record contains your symptoms, examination and test
results, diagnoses, treatment, and a plan for future care or treatment. It may also contain correspondence and other administrative documents.

Protected health information (or "PHI") is any personally identifying information which when linked to health data could be used to identify an individual. This information
may be stored or transmitted in any form (for example, paper, electronic, verbal, etc.). All of this information, often referred to as your medical records, serve as a:

Basis for planning your care and treatment

Means of communication among the many health professionals involved in your care
Legal document describing the care you received
Means by which you or a third-party payer can verify that services billed were actually provided
Tool in educating health professionals
Source of data for medical research
Source of information for public health officials charged with improving the health of the nation
Tool to assess and monitor the health care being provided and the outcomes achieved

2. Your Health information Rights

With respect to that portion of your health record held by Deseret Mutual, you have the right to:

Inspect and obtain a copy of your medical record

Amend your medical record
Request a restriction on certain uses and disclosures of your PHI
Obtain an accounting of disclosures of your PHI (other than for purposes of treatment, payment, and health care operations)
Request communications of your PHI by alternative means or at alternative locations
Revoke your authorization to use or disclose PHI except to the extent that action has already been taken

3. Our Responsibilities
Deseret Mutual is required to:

Maintain the privacy of your PHI

Provide you with notice of our legal duties and privacy practices regarding information we collect and maintain about you
Abide by the terms of this notice
Notify you if we are unable to agree to a requested restriction
Accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations

We will not use or disclose your PHI without your authorization, except for treatment, payment or health-care operations, or as provided by law.

We reserve the right to change our practices and make the new provisions effective for all PHI we maintain. If we do so, we will notify you of the changes in writing.
4. For More Information or to Report a Problem
If you have any questions or if you would like additional information, you may contact Deseret Mutual's Compliance Officer by telephone (1-801-578-5600 or
1-800-777-3622), by mail (PO Box 45730, Salt Lake City, UT 84145) or by fax (1-801-578-5906).

If you believe your privacy rights have been violated, you can file a complaint with Deseret Mutual's Compliance Officer, or with the United States Department of Health
and Human Services, Office for Civil Rights (OCR). Complaints must be in writing and can be filed either by mail or electronically. OCR will provide further information on
its Web site about how to file a complaint (www.hhs.gov/ocr/hipaa). Please note that there will be no retaliation for filing a complaint.
5. Uses or Disclosures for Treatment, Payment, and Health Care Operations

Treatment, Payment, and Health Operations: We may use your PHI for treatment, payment, and health care operations. For example, treatment information
obtained by a nurse, physician, or other member of your health care team will be recorded in your record and used to determine the course of treatment that
should work best for you. For payment, a bill may be sent to you or a third party payer. For health care operations, we may use your health care information to
study ways to improve utilization or reduce health care costs.

6. Uses or Disclosures Permitted or Required by Law

United States Food and Drug Administration (FDA): We may disclose to the FDA PHI relative to adverse events with respect to food, supplements, product and
product defects, or post-marketing surveillance information to enable product recalls, repairs, or replacement.
Public Health: As required by law, we may disclose your PHI to public health or legal authorities charged with preventing or controlling disease, injury, or
disability.
Correctional Institution: If you become an inmate of a correctional institution, we may disclose to the institution or agents thereof PHI necessary for your health
and for the health and safety of others.
Law Enforcement or Judicial Proceedings: We may disclose certain PHI for law enforcement purposes as required by law or in response to valid subpoena.

© 2022 by Intellectual Reserve, Inc. All rights reserved.

Privacy Agreements
First Name (middle) Last Name (Legal Name) (suffix) Record number Date of birth (Age) Gender

Authorization to Disclose Protected Health Information

Who Can Release the Information:

1. The Church and its affiliated entities, including The Church of Jesus Christ of Latter-day Saints Family Services
(Family Services) and, if I am called to serve a proselyting mission, Deseret Mutual Benefit Administrators (DMBA)
and DMBA's business associates.
2. Any and all other healthcare providers and/or facilities (including mental health professionals) who have treated me
before or after this authorization.

Who Can Receive Information:

1. Representatives and employees of the Missionary Department and the Risk Management Division of The Church
of Jesus Christ of Latter-day Saints.
2. General Authorities of The Church of Jesus Christ of Latter-day Saints
3. My home unit priesthood leaders (such as the bishop and stake president) and clerks who may help my local
priesthood leaders (such as ward and stake clerks)
4. My mission leadership couple (for proselyting missionaries). This includes my mission president, historic site
president, temple president, or visitors’ center director and spouse, depending on my assignment
5. Individuals serving on the Mission Health Council (for proselyting missionaries)
6. DMBA, including its Missionary Medical Department (for proselyting missionaries)
7. Missionary Training Center personnel (for proselyting missionaries)
8. Any healthcare providers who treat me in connection with my missionary service, including Family Services or BYU
Student Health Center personnel.
9. Representatives and employees of the Human Resource Department of The Church of Jesus Christ of Latter-day
Saints (for service missionaries)
10. Service mission leaders and coordinators (for service missionaries)
11. To the extent reasonably necessary to manage my missionary service, charities or civic organizations where I am
assigned (for service missionaries)

I authorize the release of my medical information to the following individuals:

Name of Individual Relationship

The Information to Be Released:

My protected health information (PHI). PHI is individually identifiable information about an individual's past, present, or future physical or mental health that is maintained
or transmitted by a healthcare provider or health plan. PHI includes, but is not limited to, medical records, symptoms, diagnoses, treatments, prognosis, lab results,
medications, and information about insurance, claims and payment.

The Purpose for Releasing the Information:

For the overall evaluation of my health and fitness to serve as a missionary, to coordinate and manage my missionary assignments, and if I am called to serve a
proselyting mission for the management and administration of my health care while serving as a missionary for The Church of Jesus Christ of Latter-day Saints.

Expiration Date:

This authorization is valid from the date of execution until 12 months after I am released from my mission, unless revoked in writing before that time. I may revoke this
authorization by writing to DMBA, Attention: Missionary Medical Department, P.O. Box 45730, Salt Lake City, Utah 84145 (for proselyting missionaries) or to the Church
Data Privacy Office at [email protected] (for service missionaries). Revocation becomes effective only after it is received by DMBA or the
Church Data Privacy Office, and the revocation will not apply to use and/or disclosure of PHI that occurs before the written revocation is received.

I certify that the above information is true and complete. I have a right to receive a copy of this authorization. I may revoke this authorization by writing to Deseret Mutual
Benefit Administrators, Attention: Missionary Medical Division, PO Box 45730, Salt Lake City, UT 84145-0730. Revocation will be valid only for future acts and will not be
valid for any action prior to receiving my revocation. Any information used or disclosed pursuant to this authorization may be subject to redisclosure and may, therefore,
no longer be protected by privacy regulations.

If I am called to serve a proselyting mission, my treatment, payment, enrollment, or eligibility for applicable medical care will not be conditioned upon my providing this
authorization except as may otherwise be permitted by applicable law. However, I understand and agree that my refusal to sign or my revocation of this authorization may
affect my eligibility to serve or continue serving as a missionary for The Church of Jesus Christ of Latter-day Saints.

I Accept I Do Not Accept

Candidate's Signature Date

© 2022 by Intellectual Reserve, Inc. All rights reserved.

Privacy Agreements
First Name (middle) Last Name (Legal Name) (suffix) Record number Date of birth (Age) Gender

Authorization for Use and Disclosure of Psychotherapy Notes

Who Can Release the Information:

1. The Church and its affiliated entities, including The Church of Jesus Christ of Latter-day Saints Family Services
(Family Services) and, if I am called to serve a proselyting mission, Deseret Mutual Benefit Administrators (DMBA)
and DMBA's business associates.
2. Any and all other healthcare providers and/or facilities (including mental health professionals) who have treated me
before or after this authorization.

Who Can Receive Information:

1. Representatives and employees of the Missionary Department and the Risk Management Division of The Church
of Jesus Christ of Latter-day Saints.
2. General Authorities of The Church of Jesus Christ of Latter-day Saints
3. My home unit priesthood leaders (such as the bishop and stake president) and clerks who may help my local
priesthood leaders (such as ward and stake clerks)
4. My mission leadership couple (for proselyting missionaries). This includes my mission president, historic site
president, temple president, or visitors’ center director and spouse, depending on my assignment
5. Individuals serving on the Mission Health Council (for proselyting missionaries)
6. DMBA, including its Missionary Medical Department (for proselyting missionaries)
7. Missionary Training Center personnel (for proselyting missionaries)
8. Any healthcare providers who treat me in connection with my missionary service, including Family Services or BYU
Student Health Center personnel.
9. Representatives and employees of the Human Resource Department of The Church of Jesus Christ of Latter-day
Saints (for service missionaries)
10. Service mission leaders and coordinators (for service missionaries)
11. To the extent reasonably necessary to manage my missionary service, charities or civic organizations where I am
assigned (for service missionaries)

The individuals listed below will also have access to your psychotherapy notes
Name of Individual Relationship

The Information to Be Released:

My psychotherapy notes, including notes recorded in any medium by a mental health professional that document or analyze conversations from private, group, joint, or
family counseling sessions and that are separated from the rest of my medical record.

The Purpose for Releasing the Information:

For the overall evaluation of my health and fitness to serve as a missionary, to coordinate and manage my missionary assignments, and if I am called to serve a
proselyting mission for the management and administration of my health care while serving as a missionary for The Church of Jesus Christ of Latter-day Saints.

Expiration Date:

This authorization is valid from the date of execution until 12 months after I am released from my mission, unless revoked in writing before that time. I may revoke this
authorization by writing to DMBA, Attention: Missionary Medical Department, P.O. Box 45730, Salt Lake City, Utah 84145 (for proselyting missionaries) or to the Church
Data Privacy Office at [email protected] (for service missionaries). Revocation becomes effective only after it is received by DMBA or the
Church Data Privacy Office, and the revocation will not apply to use and/or disclosure of PHI that occurs before the written revocation is received.

I certify that the above information is true and complete. I have a right to receive a copy of this authorization. I may revoke this authorization by writing to Deseret Mutual
Benefit Administrators, Attention: Missionary Medical Division, PO Box 45730, Salt Lake City, UT 84145-0730. Revocation will be valid only for future acts and will not be
valid for any action prior to receiving my revocation. Any information used or disclosed pursuant to this authorization may be subject to redisclosure and may, therefore,
no longer be protected by privacy regulations.

If I am called to serve a proselyting mission, my treatment, payment, enrollment, or eligibility for applicable medical care will not be conditioned upon my providing this
authorization except as may otherwise be permitted by applicable law. However, I understand and agree that my refusal to sign or my revocation of this authorization may
affect my eligibility to serve or continue serving as a missionary for The Church of Jesus Christ of Latter-day Saints.

I Accept I Do Not Accept

Candidate's Signature Date

© 2022 by Intellectual Reserve, Inc. All rights reserved.

 Christopher J. Macariola
45-C J Ocampo St
Barangay Milagrosa
Project 4, Quezon City
1109 Metro Manila
Philippines

For many members of The Church of Jesus Christ of Latter-day Saints, missionary service is a significant
milestone in their lifelong spiritual growth. Church leaders desire that this sacred time of service be a joyous
and faith-building experience for every missionary, from young men and women to senior couples. With this
goal in mind, it is imperative that each missionary be appropriately prepared, worthy, and healthy.

During the interview process, your priesthood leaders will ask you the following questions. Please direct any
questions you may have to your priesthood leaders.

These questions contain links to more information from the scriptures, Preach My Gospel: A Guide to
Missionary Service, and For the Strength of Youth. Please read and study all of this information.

Interview Questions

1. Do you have faith in and a testimony of God the Eternal Father; His Son, Jesus Christ; and the Holy
Ghost?
2. Do you have a testimony that Jesus Christ is the only begotten Son of God and the Savior and Redeemer
of the world? Please share your testimony with me. How has the Atonement of Jesus Christ influenced
your life?
3. What does it mean to you to repent? Do you feel that you have fully repented of past transgressions?
4. Will you share your testimony with me that the gospel and Church of Jesus Christ has been restored
through the Prophet Joseph Smith and that [current Church President] is a prophet of God?
5. Do you have a testimony of the truthfulness of the Book of Mormon?
6. Full-time missionary service requires living gospel standards. What do you understand about the
following standards?
1. The law of chastity
2. In reference to the law of chastity, have you always lived in accordance with what has been
discussed? If not, how long ago did the transgression(s) occur? What have you done to repent?
3. Avoiding pornography
4. The law of tithing
5. The Word of Wisdom, including the use of drugs or the abuse of prescribed medications
6. Keeping the Sabbath day holy
7. Being honest in all you say and do
Have you lived in accordance with all of these standards? Are you now living in accordance with
them? Will you live in accordance with them as a full-time missionary?
7. Do you have any legal actions pending against you?
8. Have you ever committed a serious violation of criminal law regardless of whether or not you were
arrested, you were convicted, or the record was expunged?
9. Have you ever sexually abused a child in any way, regardless of whether or not you were charged, you

© 2022 by Intellectual Reserve, Inc. All rights reserved.

 9.
were convicted, or the record was expunged?
10. Have you ever committed any other serious transgression or misdeed that should be resolved before your
mission?
11. Do you support, affiliate with, or agree with any group or individual whose teachings or practices are
contrary to or oppose those accepted by The Church of Jesus Christ of Latter-day Saints?
12. Do you have any unpaid debts? How will these debts be paid off before your mission or managed while
you serve a mission?
13. Do you currently have or have you ever had any physical, mental, or emotional condition that would
make it difficult for you to maintain a normal missionary schedule, which requires that you work for
12–15 hours a day, including studying for 2–4 hours a day, walking or biking for up to 8–10 hours a day,
and so forth?
14. Have you ever been diagnosed with or received treatment for dyslexia or other reading disorders? If so,
are you comfortable reading the scriptures and other documents aloud? Do you believe that you could
memorize appropriate scriptures and other information with the assistance of your companion? In what
ways do you now compensate for this disorder?
15. Have you ever been diagnosed with or received treatment for a speech disorder? If so, are you
comfortable speaking in front of others? Do you feel that you have adequate tools to help you learn,
teach, and communicate?
16. Have you ever been on medication or otherwise treated for any of the following conditions: attention
deficit disorder (ADD), attention deficit hyperactivity disorder (ADHD), anxiety, depression, obsessive
compulsive disorder (OCD), or autism spectrum disorder (including Asperger’s)? If yes, please explain.
17. If you were being treated for one of these conditions and discontinued treatment, did you do so under a
doctor’s supervision? If not, why did you stop? How well have you been functioning without treatment
or medication? When was the last time you were on medication for these issues?

© 2022 by Intellectual Reserve, Inc. All rights reserved.

 Missionary Recommendation

Christopher J. Macariola
45-C J Ocampo St
Barangay Milagrosa
Project 4, Quezon City
1109 Metro Manila
Philippines

Personal Information
First Name (middle) Last Name (Legal Name) (suffix)

Home street address

City State or province Postal code

Country District (if any) Airport

Periodically it may become necessary for the Missionary Department to communicate with you. Please
provide the following contact information.
Home phone (include area Mobile phone (indicate Can you receive SMS (text) messages
code) country and include area at this mobile number?
code) Yes No

E-mail address

All states, provinces, or countries where you have lived recently (or for extended periods)

Address where correspondence should be sent, if different from home address

City State or province Postal code

Country District (if any)

Phone (include area code) Gender

Male Female
Date of birth Confirmation date

Have you ever been

Widowed Divorced
Have you ever been arrested?
Yes No
Have you ever had a police record?
Yes No
Have you ever been convicted of a crime?
Yes No
(If yes to any of these, explain, including date of arrest, charge, and resolution.)

If any of your personal information will be changing prior to your mission, please explain. If your information changes after submitting your recommendation forms,
please notify your priesthood leader so he can call the Missionary Department in Salt Lake City, UT, USA.

© 2022 by Intellectual Reserve, Inc. All rights reserved.

Missionary Recommendation
First Name (middle) Last Name (Legal Name) (suffix) Record number Date of birth (Age) Gender

Citizenship Information
Citizenship at birth Place of birth (City, Birth country Current country of citizenship If dual citizenship, indicate
State/Province) second country of citizenship.

Do you have an official birth certificate? Are you currently a documented citizen of your resident country? If no, indicate your current status in your
Yes No country of residence.
Yes No
Have you ever lived in a country while not properly If yes, please provide dates, locations, and circumstances of when you lived in a country while not properly
documented to be in that country? documented to be in that country.
Yes No
Have you ever stayed in a country beyond the time If yes, please provide dates, locations, and circumstances of when you stayed in a country beyond the time
allowed by your visa? allowed by your visa.
Yes No
Does your citizenship status impose restrictions on What are the nationalities of your ancestors?
traveling outside the country where you live?
Yes No
Do you have a current passport? When does your passport expire?
Yes No
Your name as it appears on your passport. (middle) Last Name (Legal Name) (suffix)
(First)

Passport Number Country of Issue

Please provide any other information you would like to have considered regarding your citizenship. If you have multiple current passports, please provide the country and
expiration date of each passport.

Identification Information
Do you have a current driver's license? Alternate Form of I.D. I.D. Type
Yes No Yes No
Your name as it appears on your (middle) Last Name (Legal Name) (suffix) ID Number
I.D. (First)

Country State or province Expiration date

Has your driver's license ever been suspended? If yes, please provide the date and reason for the suspension.
Yes No
Emergency Contact Information
Name Relationship

Address of emergency contact

City State or province Postal code

Country District (if any) Phone of emergency contact (include area code)

Do you have a parent, brother, sister, son, daughter, grandson, or granddaughter currently serving a mission?
If yes, list the names, relationships, and locations of any of these relatives who are currently serving missions.

© 2022 by Intellectual Reserve, Inc. All rights reserved.

 Life Experience

Christopher J. Macariola
45-C J Ocampo St
Barangay Milagrosa
Project 4, Quezon City
1109 Metro Manila
Philippines
First Name (middle) Last Name (Legal Name) (suffix) Record number Date of birth (Age) Gender

Language Information
What is your primary language?

Additional languages? Please select the rating that best describes your current command of the language.
If you speak another language, select it from the 1 2 3 4 5
list below.

If you speak another language, select it from the 1 2 3 4 5

list below.

If you speak another language, select it from the 1 2 3 4 5

list below.

If you speak another language, select it from the 1 2 3 4 5

list below.

1 2 3 4 5

Key: 1 - Satisfy minimum courtesies (greetings)

2 - Converse simply about family and hobbies
3 - Converse about news and current events
4 - Comfortably handle professional situations
5 - Native
What language would you like your call letter printed in?

Indicate how interested you are in learning a language.

Very interested Interested Slightly interested Not interested
Rate how successful you feel you would be in learning a language for your mission.
Very successful Successful Slightly successful Not successful
Please express other thoughts you would like to have considered about your language skills and experience.

Education and Work Experience

How many years did you attend Did you graduate from seminary?
seminary and/or institute? Yes No
What is the highest level of education you have achieved?

Beginning with the most recent, please provide a brief summary of your skills, education, and experience at work, at home, and in the community.

Special Skills and Proficiencies N = Little to No Expertise, I = Intermediate Skill, A = Advanced Skill.
Level of expertise Skill or profession Clarifications, if any
N I A
Education Administration

Music - Choir Directing

Music - Conducting

Music - Organ

Music - Piano

School Teacher - Elementary/Secondary

Level of expertise Skill or profession Clarifications, if any

N I A
School Teacher - College

School Teacher - ESL

Social Work

Automotive Mechanic

Building Contractor

© 2022 by Intellectual Reserve, Inc. All rights reserved.

 Building Maintenance

Building Management

Carpentry

Electrician

Painter

Plumbing

Welding

Computer - Database Administration

Computer - PC Administration

Computer - Software Engineering

Computer - Spreadsheet

Computer - Word Processing

Engineer - Chemical

Engineer - Civil

Engineer - Electrical

Engineer - Mechanical

Attorney / Judge

Communications

Family Finances

Finance - Bookkeeping

Finance - General Accounting

Finance - Tax Accounting

Office Manager

Receptionist

Sales

Level of expertise Skill or profession Clarifications, if any

N I A
Secretary

Family History Research

Farming

Gardening

Heavy-Equipment Operator

Homemaking

Landscaping

Truck Driver

Dental Hygienist

© 2022 by Intellectual Reserve, Inc. All rights reserved.

 Elder Care

Medical - Doctor

Medical - Licensed Practitioner Nurse

Medical - Nurse Practitioner

Medical - Paramedic

Medical - Physician Assistant

Medical - Psychiatrist

Medical - Psychologist

Medical - Registered Nurse

Medical - Pharmacist

Medical - Other

Add any profession or skills that were not listed above.

Church Callings (current and former) Check all that apply.

General auxiliary presidency Ward or branch Young Women presidency counselor
Temple matron Ward or branch Primary president
Assistant temple matron Ward or branch Primary presidency counselor
Temple ordinance worker Compassionate service leader
Stake or district Relief Society president Visiting teaching coordinator
Stake or district Relief Society presidency counselor Ward or stake missionary
Stake or district Young Women president Scout leader
Stake or district Young Women presidency counselor Sunday School teacher
Stake or district Primary president Teacher in auxiliary organization
Stake or district Primary presidency counselor Seminary or institute teacher
Ward or branch Relief Society president Family history center
Ward or branch Relief Society presidency counselor Family history specialist
Ward or branch Young Women president FamilySearch indexing
Please list the temples where you have served in a calling or as an ordinance worker.

Please tell us about any other Church service that you would like to have considered.

Prior Mission Experience

Have you served other full-time missions?
Yes No
Beginning with the most recent, please tell us about each of your prior missions. To add a mission, click Add Another. To remove a mission, click Remove next to the
row to be removed.
From To In which state or country did you serve? What type of mission was it?

Please provide any additional information about previous full-time mission experiences that you would like to have considered.

© 2022 by Intellectual Reserve, Inc. All rights reserved.

Life Experience
First Name (middle) Last Name (Legal Name) (suffix) Record number Date of birth (Age) Gender

Military Information
Do you have current or previous military experience? Name of military organization or branch of military service
Yes No
Are you retired military?
Yes No
Are you a current member of a military reserve unit? Name of reserve organization
Yes No
Name of commanding officer

Unit mailing address City

Country

State or province Postal code

Please list any additional details about your military service that you would like to be considered.

© 2022 by Intellectual Reserve, Inc. All rights reserved.

 Assignment Preferences

Christopher J. Macariola
45-C J Ocampo St
Barangay Milagrosa
Project 4, Quezon City
1109 Metro Manila
Philippines
First Name (middle) Last Name (Legal Name) (suffix) Record number Date of birth (Age) Gender

Finances
Total to be paid per month Indicate how much money (in your local currency) will be contributed per month in support of your mission from the sources
below. Enter single combined amount for a couple in “Self.”
Local currency
Self (per month) Family (per month) Ward or branch (per month) Other (per month) Total to be paid per month

Of the above total amount, how much will you commit to pay per month
toward your housing expenses?
Please let us know anything else you would like to have considered about your finances.

Timing
Mission calls vary in length. Please indicate the maximum amount of time you can Date available to serve
serve, understanding that you may be called to serve for a shorter duration.
23 months 18 months 12 months 6 months
Do you have a reverse mortgage? (Please note that the conditions of many reverse mortgages restrict how long you may be out of your home. For details, contact your
mortgage lender.)
Yes No
Please tell us about any limitations or special circumstances related to your term of service.

Location
Where would you prefer to serve?
In own country Outside own country No preference
Senior missionaries from the United States and Canada who serve a mission within the United States or Canada are expected to take their car to their mission. If you are
asked to serve in the United States or Canada, will you be able to take your car to your mission?
Yes No
In the space below, please address the following:

Limitations: Provide clarifications or explanations regarding your answer above.

Requests: If someone has requested that you serve in a specific mission, note the name of the individual and the mission.

© 2022 by Intellectual Reserve, Inc. All rights reserved.

 Unit Information for Missionary Candidate

Christopher J. Macariola
45-C J Ocampo St
Barangay Milagrosa
Project 4, Quezon City
1109 Metro Manila
Philippines
First Name (middle) Last Name (Legal Name) (suffix) Record number Date of birth (Age) Gender

Home Unit Information

Home ward or branch Unit number Home stake or mission Unit number

Name of home bishop or branch president Name of home stake or mission president

Mailing address (including country) Mailing address (including country)

Home phone (area code) Work phone (area code) Cell phone (area code) Home phone (area code) WorkPhoneLabel Cell phone (area code)

E-mail address Fax E-mail address Fax

Submitting Unit Information (If other than home unit)

Ward or branch Unit number Stake or mission Unit number

Name of bishop or branch president Name of stake or mission president

Mailing address (including country) Mailing address (including country)

Home phone (area code) Work phone (area code) Cell phone (area code) Home phone (area code) Work phone (area code) Cell phone (area code)

E-mail address Fax E-mail address Fax

Funding Unit Information (If other than home unit)

Ward or branch Unit number Stake or mission Unit number

Name of bishop or branch president Name of stake or mission president

Mailing address (including country) Mailing address (including country)

Home phone (area code) Work phone (area code) Cell phone (area code) Home phone (area code) Work phone (area code) Cell phone (area code)

E-mail address Fax E-mail address Fax

Membership Unit Information (If other than home unit)

Ward or branch Unit number Stake or mission Unit number

Name of bishop or branch president Name of stake or mission president

Mailing address (including country) Mailing address (including country)

Home phone (area code) Work phone (area code) Cell phone (area code) Home phone (area code) Work phone (area code) Cell phone (area code)

E-mail address Fax E-mail address Fax

© 2022 by Intellectual Reserve, Inc. All rights reserved.

 Health Insurance Information of Prospective Missionary

Christopher J. Macariola
45-C J Ocampo St
Barangay Milagrosa
Project 4, Quezon City
1109 Metro Manila
Philippines
First Name (middle) Last Name (Legal Name) (suffix) Record number Date of birth (Age) Gender

Do you have Medicare (government sponsored health care in the United States)? Do you have other government sponsored health care?
Yes No Yes No
Do you have a private medical insurance provider? Will you be covered by a group or individual health insurance plan while serving your mission?
Yes No Yes No
Will you have coverage from another insurance company?
Yes No
Other Insurance Considerations
Please let us know anything else that may be important concerning your health insurance.

© 2022 by Intellectual Reserve, Inc. All rights reserved.

 Personal Health History of Missionary Candidate

Christopher J. Macariola
45-C J Ocampo St
Barangay Milagrosa
Project 4, Quezon City
1109 Metro Manila
Philippines
First Name (middle) Last Name (Legal Name) (suffix) Record number Date of birth (Age) Gender

Please answer all of the following questions. Be honest with yourself, your physician, and the Lord. Major difficulties may result if this
information is not complete and accurate. Please do not withhold or deny any medical information.

Key: Current = is currently occurring; Previous = occurred previously, but is now resolved; Never = has never occurred
Current Previous Never 1.1 Injury to head

Current Previous Never 1.2 Headaches (migraine, tension, or other serious headaches)

Current Previous Never 1.3 Seizures (convulsions, epilepsy) multiple sclerosis, or Parkinson's disease

Current Previous Never 1.4 Dizziness or fainting

Current Previous Never 1.5 Stroke

Current Previous Never 1.6 Loss of balance sense

Current Previous Never 1.7 Memory loss, dementia, or speech or learning difficulties

Current Previous Never 2.1 Visual impairment, not correctable

Current Previous Never 2.2 Glaucoma, cataracts, macular degeneration, or retinal detachment

Current Previous Never 2.3 Major hearing loss not corrected by hearing aid

Current Previous Never 2.4 Sinus problems

Current Previous Never 2.5 Sleep apnea

Current Previous Never 2.6 Mouth/dental problems needing correction

Yes No 2.7 Do you wear full-mouth dentures?

Current Previous Never 3.1 Asthma

Current Previous Never 3.2 Emphysema or chronic lung disease

Current Previous Never 3.3 Tuberculosis, chronic cough, coughing up blood, positive PPD skin test, or unexplained fatigue or fever

Current Previous Never 3.4 Pneumonia

Current Previous Never 3.5 Collapsed lung (pneumothorax)

Current Previous Never 3.6 Pulmonary embolism (blood clot to lungs)

Current Previous Never 4.1 Arthritis or joint pain

Current Previous Never 4.2 Joint replacement or other joint operation

Current Previous Never 4.3 Fractures

Current Previous Never 4.4 Osteoporosis

Current Previous Never 4.5 Loss of limb or major limb deformity

Current Previous Never 4.6 Paralysis, muscle weakness, or numbness

Current Previous Never 4.7 Difficulty walking or climbing stairs

Current Previous Never 4.8 Require cane, crutch, walker, wheelchair, or other mobility device

Current Previous Never 5.1 Degenerative disk disease

Current Previous Never 5.2 Chronic neck or back pain

Current Previous Never 5.3 Operation on spine

Current Previous Never 5.4 Scoliosis or spinal curvature

Current Previous Never 6.1 Problems with being overweight

Current Previous Never 7.1 Acne, eczema, or other skin condition

Current Previous Never 8.1 Hypertension or high blood pressure

Current Previous Never 8.2 Coronary artery disease (angina chest pain, prior heart attack, angiogram, stent, or bypass grafts)

© 2022 by Intellectual Reserve, Inc. All rights reserved.

Current Previous Never 8.3 Heart valve disease, repair, or replacement

Current Previous Never 8.4 Irregular heart rhythm, medically treated, ablation procedure, pacemaker, or internal defibrillator

Current Previous Never 8.5 Heart failure, chronic

Current Previous Never 8.6 Congenital heart condition

Current Previous Never 9.1 Acid reflux or ulcers

Current Previous Never 9.2 Irritable bowel, pain, constipation, or chronic diarrhea

Current Previous Never 9.3 Ulcerative colitis or Crohn's disease

Current Previous Never 9.4 Diverticulosis, diverticulitis of colon

Current Previous Never 9.5 Rectal bleeding

Current Previous Never 9.6 Gastritis

Current Previous Never 9.7 Hernia

Current Previous Never 10.1 Gall stones or gall bladder disease

Current Previous Never 10.2 Hepatitis, chronic type B or C

Current Previous Never 10.3 Cirrhosis

Current Previous Never 11.1 Kidney stones

Current Previous Never 11.2 Kidney failure/dialysis

Current Previous Never 11.3 Kidney and bladder infections

Current Previous Never 11.4 Frequent or difficult urination

Current Previous Never 11.5 Urine incontinence

Current Previous Never Male: varicocele, prostate enlarged, operation on prostate gland (not for cancer), prostate infection, or known sexually
12.1
transmitted disease
Current Previous Never 13.1 Diabetes mellitus type I or II

Current Previous Never 13.2 Thyroid function increased or decreased, gland enlarged or nodules, or thyroid gland removal

Current Previous Never 13.3 Adrenal

Current Previous Never 13.4 Other endocrine issues

Current Previous Never 14.1 Leukemia

Current Previous Never 14.2 Anemia

Current Previous Never 14.3 Clotting abnormality (prolonged bleeding, excessive clotting, or deep vein thrombosis)

Current Previous Never 14.4 Taking anticoagulant medications

Current Previous Never 14.5 Peripheral vascular disease or pain in legs while walking

Current Previous Never 14.6 Aneurysm (enlargement of artery)

Current Previous Never 15.1 Tumor (non-malignant)

Current Previous Never 15.2 Malignant cancer of any organ

Current Previous Never 15.3 Skin cancer or melanoma

Current Previous Never 15.4 Screening tests for cancer; lung, colon, breast, uterus, or prostate

Current Previous Never 16.1 Allergies requiring shots or other allergy prescription medications

Current Previous Never 16.2 Food allergy or intolerance

Current Previous Never 16.3 Lupus erythematosus, scleroderma, or rheumatoid arthritis

Current Previous Never 16.4 Organ transplant

Current Previous Never 17.1 Depression (including suicidal plans or attempts)

Current Previous Never 17.2 Anxiety

Current Previous Never 17.3 Bipolar disorder, schizophrenia, obsessive compulsive disorder, psychosis, or eating disorder (bulimia, anorexia)

Current Previous Never 17.4 Insomnia

Current Previous Never 18.1 Chronic fatigue or pain syndrome, Fibromyalgia syndrome

Current Previous Never 19.1 Any hospitalization, disease, injury, or regularly required health care not previously listed

Current Previous Never 20.1 Adverse reaction to medication

Yes No Are you currently taking any prescription medications, herbal medications, alternative treatments, or diet
20.2
supplements?

© 2022 by Intellectual Reserve, Inc. All rights reserved.

© 2022 by Intellectual Reserve, Inc. All rights reserved.
All missionaries, including those serving in their resident country, are required to receive immunization for tetanus/diphtheria and hepatitis A and B . In addition,
missionaries born after 1957 also require immunizations for measles/mumps/rubella (MMR 1 and 2) and polio. Although the immunizations are not required before
completing this form, they should be completed as soon as possible before entering the MTC. While not required, senior missionaries are also encouraged to be
vaccinated against pneumonia and shingles.

Please select the full date you received each of the following immunizations. If you do not have record of or cannot recall the exact date, provide your best estimate. If you
have not received an immunization, leave the date blank.
21.1 Tetanus/diphtheria/pertussis #1
21.2 Tetanus/Diphtheria/Pertussis (TDAP)
21.3 MMR1
21.4 MMR2
21.5 Polio
21.6 Hepatitis A #1
21.7 #2
21.8 AND hepatitis B #1
21.9 #2
21.10 #3
21.11 OR combined hepatitis A and B #1
21.12 #2
21.13 #3
21.14 Influenza
21.15 COVID-19 Pfizer & BioNTech #1
21.16 #2
21.17 COVID-19 Moderna #1
21.18 #2
21.19 COVID-19 CureVac #1
21.20 #2
21.21 COVID-19 Sputnik V #1
21.22 #2
21.23 COVID-19 Oxford-Astrozeneca #1
21.24 #2
21.23 COVID-19 Covaxin #1
21.24 #2
21.23 COVID-19 Sinovac #1
21.24 #2
21.26 COVID-19 BBIBP #1
21.24 #2
21.25 COVID-19 CanSinoBIO
21.26 COVID-19 Johnson & Johnson
Yes No 21.27 If necessary, will you receive additional vaccinations (including the COVID-19 vaccine)?
Declaration and Authorization by Prospective Missionary
I declare that the statements made in the Personal Health History of Prospective Missionary are a complete and honest report of my
health history. No personal health information has been withheld or misrepresented.

I hereby authorize The Church of Jesus Christ of Latter-day Saints to collect, process, and transfer to other countries for Church
purposes my personal data, including sensitive data, in accordance with the Church's Global Privacy Notice.
Prospective missionary's signature Date

© 2022 by Intellectual Reserve, Inc. All rights reserved.

 Physician's Evaluation for Senior Prospective Missionary

Christopher J. Macariola
45-C J Ocampo St
Barangay Milagrosa
Project 4, Quezon City
1109 Metro Manila
Philippines
First Name (middle) Last Name (Legal Name) (suffix) Record number Date of birth (Age) Gender

Instructions for Physicians Evaluating Missionary Candidates

General Instructions: 8. In addition to the examining health care provider, the
1. The Physician's Evaluation may be completed by a: medical prospective missionary must also sign the completed form.
doctor (MD), osteopathic doctor (DO), physician assistant (PA), 9. Return this completed and signed evaluation form, any needed
or advanced nurse practitioner (NP). (These are referred to as attachments, and the prospective missionary's signed Health
"health care providers".) An examination by any other History form to the prospective missionary.
practitioner is not acceptable.
2. The following tests are recommended for all missionaries: To the Prospective Missionary:
a. A colonoscopy if over 50 years old; 1. Take this Physician's Evaluation form and your signed Health
b. A mammogram for sisters if over 40 years old; History form to your medical examination. Your health care
c. A stress test is required if there are significant risks for orprovider will complete the evaluation form and return both forms
symptoms of coronary artery disease or if there is known history to you.
of coronary artery disease. 2. If a surgery or procedure has occurred within approximately the
Note: Those who do not complete these tests as indicated will last 6 months, you must provide an explanation of the outcome
not be considered for foreign missions and will serve in the and current recovery status from the performing health care
country where they reside. provider.
3. If you are taking prescription medication for any chronic
problem or medical or emotional condition, continue taking the
To the Examining Health Care Provider: medication unless advised by your health care provider.
1. To be valid, the examination associated with the information 4. All anticipated procedures and surgeries must be completed
on this form should have been done within the last year. prior to submitting your recommendation forms.
2. The prospective missionary's Health History form should be 5. You must sign the Physician's Evaluation form to allow the form
reviewed during the examination to assure evaluation of to be used as part of your missionary recommendation.
self-reported conditions. 6. Give the completed and signed Physician's Evaluation form,
3. Medical conditions should be stabilized prior to attesting to the any needed attachments, and your Health History form to your
prospective missionary's medical status. This includes new bishop or branch president.
conditions diagnosed during the examination, as well as known
conditions requiring altered medication regimens and care. To the Priesthood Leader:
4. When a recent major illness, operation, injury, hospitalization, 1. Review the entire form to ensure that all applicable questions
or prolonged treatment is reported, please attach a summary have been answered.
report of the incident from the professional who provided 2. Scan and attach all documents provided by the health care
treatment. provider.
5. If the prospective missionary is referred to specialty care, 3. All anticipated procedures and surgeries must be completed
please attach that specialist's evaluation and conclusions. prior to submitting the recommendation forms.
6. Required laboratory tests: 4. Ensure that the form has been signed and dated by both the
• Hemoglobin or Hematocrit health care provider and the prospective missionary.
• Dipstick Urine: blood, protein, sugar 5. The original, signed evaluation form and Health History form
• Tuberculosis screening should be kept in a secured file at the stake until the missionary
7. Please mark the appropriate box in the "Assessment of has been released for one year, at which time the forms should be
Functional Ability" at the end of the evaluation to indicate the burned or shredded.
prospective missionary's overall ability to function.

© 2022 by Intellectual Reserve, Inc. All rights reserved.

Physician's Health Evaluation for Prospective Missionary
First Name (middle) Last Name (Legal Name) (suffix) Record number Date of birth (Age) Gender

To the physician: Please type, print, or write legibly in black ink when completing this form. Attach additional information if
necessary. Return this completed and signed evaluation form, any needed attachments, and the prospective missionary's signed
Health History form to the prospective missionary. Your thorough evaluation and completion of all requested forms, information, and
recommendations will be greatly appreciated.
Height (in inches or centimeters) Weight (in pounds or kilograms) Blood pressure Pulse Vision (with corrective lenses, if required)
in. cm. lbs. kg. / Left Right
General appearance Attention: If a test result is abnormal, please refer to item number, give details of the repeat or
Normal Abnormal additional testing, and describe treatment or other consultation if needed.
Skin
Normal Abnormal
Eyes
Normal Abnormal
Ears/balance (audiogram if necessary)
Normal Abnormal
Nose, throat, neck, and thyroid
Normal Abnormal
Chest and lungs
Normal Abnormal
Heart and blood vessels (murmurs)
Normal Abnormal
Abdomen (masses, liver, and spleen)
Normal Abnormal
Genitalia, varicocele, hernia, and pilonidal area
Normal Abnormal
Prostate (if recommended by clinician)
Normal Abnormal
Back (history of pain, disability, treatment; also pilonidal disease)
Normal Abnormal
Upper extremities
Normal Abnormal
Lower extremities
Normal Abnormal
Neurological system
Normal Abnormal
(Women only) breasts
Normal Abnormal Not indicated
(Women only) Reproductive organs: pelvic examination required
only if symptomatic, previously sexually active, or over age 40
(including PAP test completed within last 2 years).
Normal Abnormal

© 2022 by Intellectual Reserve, Inc. All rights reserved.

Physician's Evaluation for Senior Prospective Missionary
First Name (middle) Last Name (Legal Name) (suffix) Record number Date of birth (Age) Gender

17. Urinalysis (not required for young missionaries; enter actual test results or “not Attention: If a test result is abnormal, please refer to item number, give details of
done”) the repeat or additional testing, and describe treatment or other consultation if
• Dipstick—blood (required) needed.
• Dipstick—protein (required)
• Dipstick—sugar (required)
• Microscopic (if dipstick abnormal)
18. Hemoglobin or hematocrit (check the type and enter the test result)
Hematocrit (%) Hemoglobin (g/dl)

PSA testing (if indicated)

Mammogram (within last year for females over 40)

19. Tuberculosis (TB) screening:

TB exposure risk: Has the prospective missionary been exposed to any person
with active tuberculosis, or lived or worked in a circumstance of high tuberculosis
incidence such as a country, health care facility, shelter, jail, or reservation?
Yes No
Tuberculosis screening (PPD skin test or interferon test or X-ray) is required for
all prospective missionaries, including those who had BCG vaccine and/or those
who are known to be skin-test positive. Where PPD or interferon are not
available, a chest X-ray is required.

A chest X-ray is also required in any of the following circumstances:

1. The prospective missionary has a low TB risk (answered NO to TB exposure
risk above) and the PPD is 15mm or greater.
2. The prospective missionary has a high TB risk (answered YES to TB
exposure risk above) and has a PPD of 10mm or greater.
3. The interferon test is positive.
Screening results:
PPD millimeters of induration
mm PPD not done
Interferon results
Negative Positive Not Done
Chest X-ray results
Normal Abnormal Not Done
TB comments / follow-up plan (required if X-ray is abnormal)

Is the prospective missionary currently taking any medication or is there any other
factor that might impair their ability to drive? (If yes, explain.)
Yes No
27. Exercise Electrocardiography (Stress Test):
Required if the prospective missionary has ever had coronary artery bypass
surgery, coronary angioplasty, or coronary stent placement.
Recommended for those with three or more of the following risk factors:
Prospective missionary is a male over 50 years old.
Prospective missionary has hypertension.
Prospective missionary has hypercholesterolemia.
Prospective missionary has diabetes mellitus, is obese, or has metabolic
syndrome.
Prospective missionary has a family history of early onset coronary artery
disease.
Prospective missionary has had chest pain consistent with angina
pectoris.
Date of Test Normal Abnormal

© 2022 by Intellectual Reserve, Inc. All rights reserved.

Physician's Evaluation for Senior Prospective Missionary
First Name (middle) Last Name (Legal Name) (suffix) Record number Date of birth (Age) Gender

28. Diabetes Mellitus: If the prospective missionary has diabetes mellitus, the following items are Attention: If a test result is abnormal, please refer to item number,
required: give details of the repeat or additional testing, and describe
28.1 Hemoglobin A1C treatment or other consultation if needed.
Hemoglobin
A1C Lab
results:
28.2 Retinal examination by an ophthalmologist
Normal Abnormal
28.3 Kidney function
Creatinine:
Spot urine, albumin/creatinine ratio (ACR) in mg/mmol: mg/mmol
28.4 Lipid Profile
Fasting Fasting
HDL:
cholesterol: triglyceride:
28.5 Diabetic foot examination for neurological and vascular abnormalities
Normal Abnormal
28.6 Exercise electrocardiography
Normal Abnormal

Assessment of Functional Ability and Need for Medications or Medical Care Based on a review of the prospective missionary's history, your personal interview, a
physical examination, and a review of laboratory findings, indicate the prospective missionary's ability to function at various levels of activity as a missionary below.
Level A: No limitation Level B: Slight limitation Level C: Moderate limitation Level D: Marked limitation Level E: Not appropriate
(No limitation of (Slight limitation of (Moderate limitation of (Marked limitation of (Conditions exist that
activity in lifting, activity; slight decrease activity; moderate decrease of activity or has special preclude full-time
carrying, walking 6 of function or stamina, function or stamina; requires requirements, such as missionary service.)
or more miles per such as problems with limited walking (0-3 miles per specific climate, use of
day, or spending 12 walking (limited to 3-6 day) or sedentary work.) wheelchair, frequent rest
to 16 hours per day miles per day) or with periods, special medical
in missionary extensive standing.) needs, or medical visits.)
activity.)
Based on your review of this candidate's history, physical examination, laboratory tests, and consultations, please answer the following questions:

Does the missionary have any chronic physical or mental condition that will need follow-up care or continuing medication during his/her mission?
Yes No

If yes, what is the condition? by what kind of physician and how often should the missionary be seen? What medications are required? Provide your answers in the
comments box below.
Comments

Physician's signature Name of physician Date of exam

MD DO NP
Physician's office address City State or province

Country Postal code District (if any)

Office phone (with area code) E-mail address (if available)

Authorization to Release Information

I authorize the examining physician to release the information contained in the Personal Health History of Missionary Candidate and the Physician's Health Evaluation of
Missionary Candidate to my bishop or branch president and the Missionary Department of The Church of Jesus Christ of Latter-day Saints. I am aware that the
information will be screened by physicians. I am aware that the information may be used in assessing assignments as part of my missionary call. I hereby release the
examining physician from all legal liabilities that may arise from the release or use of the information by The Church of Jesus Christ of Latter-day Saints or its agents.
Missionary candidate's signature Date of signature

Witness's signature Date of signature

© 2022 by Intellectual Reserve, Inc. All rights reserved.

 Dentist's Evaluation for Senior Prospective Missionary

Christopher J. Macariola
45-C J Ocampo St
Barangay Milagrosa
Project 4, Quezon City
1109 Metro Manila
Philippines
First Name (middle) Last Name (Legal Name) (suffix) Record number Date of birth (Age) Gender

General instructions:
1. The Dentist's Evaluation is valid for one year from the date the form is signed by
the dentist. 3. Take this Dentist's Evaluation form to your dental examination.
2. Active orthodontic treatment is defined as any of the following: 4. When all required dental care has been completed or scheduled, your dentist will
a. Bonded or banded braces on the teeth. return the completed form to you.
b. Invisalign treatment trays. 5. You must sign the Dentist's Evaluation form to allow the form to be used as part of
c. Removable appliances requiring periodic adjustments. your missionary recommendation.
Note: Wearing a final retainer appliance after active orthodontic treatment is 6. Give the completed form to your bishop or branch president.
completed is not considered active treatment.
To the examining dentist: To the priesthood leader:
As you evaluate this prospective missionary's dental condition, please be aware 1. Scheduled dental care and active orthodontic treatment must be completed before
that he/she might be assigned to serve for up to two years in an area of the world a prospective missionary begins missionary service.
with limited or inadequate professional dental care. 2. All required dental treatment must be completed or scheduled before submitting
1. If the prospective missionary wears full-mouth dentures, please evaluate their the recommendation.
oral health and indicate their status in the comments section. In this situation, the 3. Ensure that the form is complete and has been signed and dated by both the
remaining questions on the form do not need to be answered. examining dentist and the prospective missionary. (See instruction #1 to the
2. When you are satisfied that all treatment has been completed or scheduled, prospective missionary for an exception to this rule.)
return the completed and signed evaluation form to the prospective missionary. 4. The original, signed evaluation form should be kept in a secured file at the stake
until the missionary has been released for one year, at which time it should be
burned or shredded.

First Name (middle) Last Name (Legal Name) (suffix) Record number Date of birth (Age) Gender

Dental Evaluation
Has the prospective missionary had a complete oral examination with bitewing radiographs within the last six months? Yes No

2. Not applicable for seniors

3. Not applicable for seniors

Has all dental decay and gum infection been resolved? Yes No

Is the prospective missionary currently undergoing active orthodontic treatment (such as braces)? Yes No

Given that this individual might not have access to professional dental care (including exams and cleanings) for 18–24 Yes No
months, do you believe that he or she will be free of dental problems for this period if proper oral hygiene is practiced?
Comments:

Dentist’s signature (Please complete all dental work before signing this form) Name of dentist Date completed or evaluated

Dentist's office address City State or province

Country Postal code District (if any)

Office phone (with area code) E-mail address (if available)

Authorization to Release Information

I authorize the examining dentist to release the information contained in this dental evaluation to my bishop or branch president and the Missionary Department of The
Church of Jesus Christ of Latter-day Saints. I am aware that the information will be screened by dentists. I am aware that the information may be used in assessing
assignments as part of my missionary call. I hereby release the examining dentist from all legal liabilities that may arise from the release or use of the information by The
Church of Jesus Christ of Latter-day Saints or its agents.
Missionary candidate's signature Date

Witness's signature Date

© 2022 by Intellectual Reserve, Inc. All rights reserved.

 Privacy Agreements

Christopher J. Macariola
45-C J Ocampo St
Barangay Milagrosa
Project 4, Quezon City
1109 Metro Manila
Philippines
First Name (middle) Last Name (Legal Name) (suffix) Record number Date of birth (Age) Gender

Authorizations, Notices, and Releases of Information

I hereby authorize The Church of Jesus Christ of Latter-day Saints, its officers, leaders, employees, affiliated entities, and departments, including (as applicable) my
mission leadership couple and my home unit priesthood leaders, such as the bishop and stake president, together with clerks and service mission leaders or coordinators
who may assist my local priesthood leaders (collectively the "Church"), to process my personal and sensitive data for purposes relating to missionary service in the
Church in accordance with the Church's Global Privacy Notice and these Privacy Agreements. (My mission leadership couple refers to the mission president and
companion, historic site president and companion, temple president and matron, and/or visitor center director and companion who oversee me, depending on my mission
assignment.).

This authorization includes the following understandings and consents:

1. The Church will have access to my personal and sensitive data, including sensitive data relating to my ethnic origin, religious
beliefs, physical and emotional health, and any criminal history, for the purposes of evaluating my missionary
recommendation, determining my missionary assignment if my recommendation is accepted, overseeing my mission, and
responding to emergencies and other circumstances that might affect my missionary service. I consent that the Church may
process my personal and sensitive data for these purposes.

2. I have informed my parents and/or caregivers that I will include some of their personal data in my missionary
recommendation.

3. My Bishop and Stake President (or Branch President, District President and Mission President, as the case may be) will
provide evaluations of my qualifications to serve as a missionary. I agree that these evaluations are related to determining
my worthiness and capacity to serve as a missionary. I understand that these evaluations are strictly confidential and I
hereby waive any right of access to these evaluations.

4. The provision of my personal data is necessary in order for the Church to process my missionary recommendation.

5. I authorize the transfer of my personal data, including sensitive data relating to my ethnic origin, religious beliefs, physical
and emotional health, and any criminal history, to Church headquarters in the State of Utah, United States of America and to
other countries with less stringent data protection laws than the country in which I reside. I understand and acknowledge that
the transfer of this information is necessary for the Church to evaluate my recommendation to serve the Church as a
missionary.

6. With the exception of ecclesiastical leaders' evaluations, I may access, upon my written request, the personal data I have
provided in connection with this missionary recommendation and I may rectify any erroneous data.

7. I understand that the Church may have occasion to film or record me in connection with my missionary service. The Church
also may have access to images and videos of me that I post on social media or on other public websites or apps while
serving as a missionary. I authorize the Church to record or copy my name, voice, image, likeness, and performance in
connection with my missionary service, and to use such recordings and copies in any way and for any purpose related to the
Church's missionary activities (including to reproduce, distribute, publish, adapt, edit, display, translate, summarize, create
derivative works from, and sublicense). I waive any right to inspect, approve, or be compensated for such recording and use.

8. If I drive or am a passenger in a Church vehicle, I authorize the Church to record telematics data, such as who is traveling,
location, movements, speed, idle time, length of stops, miles driven, fuel usage, maintenance, seat belt use, acceleration,
deceleration, rapid starts, hard turns, and accidents. Some vehicles may also record video. This data may be used as part of
the Church’s Driver Accountability Program to promote safety, respond to incidents, and protect vehicles, occupants, and
others.

9. I authorize the Church to share information about my missionary service at its discretion with governmental or similar
organizations for limited statistical or reporting purposes. I also authorize the Church to verify my mission assignment(s) and
my dates of service when contacted by third parties for post-mission employment verification, such as when the government
or a private employer asks to verify when/where I served as a part of a background check.

10. If I am called to a service mission, I authorize the Church to share my personal and sensitive data (including my contact
information, information pertaining to my physical and emotional health and capabilities, and information relating to the
performance of my missionary service) with any charities or civic organizations where I am assigned to volunteer as
reasonably necessary for the purpose of coordinating and managing my missionary service.

11. Upon completion of my mission, my general contact information may be included in a returned missionary directory

© 2022 by Intellectual Reserve, Inc. All rights reserved.

 11.
accessible to my former mission leadership couple(s) for the purpose of keeping us connected. I understand that I can opt
out or limit how my contact information is shared by modifying my profile preferences as described in the Church's Global
Privacy Notice.

12. I understand that, while the Church tries hard to protect the confidentiality of my data, when I authorize my data to be shared
under these Privacy Agreements the data may be shared via telephone, email, text message or other means that potentially
could be intercepted or read by a third party.

13. The Church will retain my personal data during my mission. Although some data will be destroyed after completion of my
mission, other data may be retained indefinitely as part of the historical or other records of the Church. Some data (such as
vehicle telematics information) will be anonymized after my personal data is no longer needed. I authorize the Church to use
and retain my data in its discretion.

14. Should I have questions concerning the protection of my personal data or the security of personal data processed by the
Church, I have been advised that I may communicate my questions to the Church's representative for data privacy at
[email protected].

Missionary Funds

I understand that all donations to the Church's missionary funds become the property of the Church to be used at the Church's sole discretion in its missionary program
and are not refundable.

Electronic Devices
The Church allows the use of technology to help me fulfill my missionary purpose. The Church may provide a device to me or I may be required to purchase a
Church-approved device, but regardless of ownership I recognize that using technology is a privilege that can be revoked. I hereby accept the responsibility to use
technology only in ways that are consistent with my missionary calling and not in any way that is obscene, defamatory, illegal, or hateful or that infringes the rights of
others. I understand that as a missionary I may have access to personal and private information of others, including non-members and members of the Church. I agree to
keep confidential all personal information contained in systems and devices to which I may have access, and commit not to share it with anyone who is not authorized.

To ensure I am using the device appropriately, I will allow the Church to inspect and monitor my use at any time. This may include: (i) tracking the movement and the
location of devices provided to me; (ii) monitoring my communications, internet searches, or downloads; (iii) remotely wiping the device of all data; or (iv) locking the
device to prevent access by unauthorized persons. I understand that if a device is wiped I may permanently lose all data that has not been backed up. I will have no
expectation of privacy when using computers or electronic devices as a missionary. I will obey all mission rules and instructions regarding use of technology, including the
use of security precautions like passwords and encryption. I agree to report a lost or stolen device to the Church immediately, to install and use only authorized software
and applications, and to abide by the terms of any licence agreements to which Church devices may be subject.

Insurance, Liability, and Medical Expense Acknowledgement

Handbook 1: Stake Presidents and Bishops indicates that all missionaries are strongly encouraged to maintain their existing medical insurance during their missions. This
conserves Church funds and helps missionaries avoid having to prove insurability after their missions. Maintaining coverage helps provide protection for past chronic or
congenital problems and post-mission medical needs. This directive is consistent with the principles of self-reliance and self-sufficiency.

Couples and single sisters ages 40 and over are responsible for their own health care expenses and must have health insurance adequate for their mission assignments.
If the insurance coverage of those living away from home is not adequate for their assignment, Deseret Mutual will send them information on additional insurance that
they may purchase. Missionaries who need additional coverage but do not enroll in the DMBA plan must provide proof of adequate coverage before their service begins.

Acknowledgement:

I understand that if I am called to a service mission, I am solely responsible for all of my medical, dental, and liability expenses.

For proselyting missionaries, I understand that if I become sick or injured during my mission, the Church may provide initial payments for my medical expenses except for
preexisting conditions. Payments in the United States will be made through Missionary Medical, a Department of Deseret Mutual Benefit Administrators (DMBA), a
not-for-profit Church affiliated entity. Payments outside the United States will be made through Aetna International and its network partners.

These payments are made from the general funds of the Church and are gratuitous and voluntary in nature. Payments are not made from a Church insurance policy and
are not intended to replace my personal health insurance.

Likewise, if I am involved in an accident while driving a Church-owned vehicle for which the Church carries insurance, but the damages attributable to me exceed the
coverage limits, the Church may seek contribution from any personal or family liability insurance policy available to me, including but not limited to automobile,
homeowner's, or general liability policies.

In either case, I understand that claims will be filed with my insurance carrier. I agree to support all recovery efforts (including assisting in claims filing and reimbursement
procedures) in the event the Church makes initial payment for medical expenses. I agree to support efforts by Missionary Medical to coordinate care directly with my
parents (when authorized for disclosure), healthcare providers, and my insurance carrier.

I understand that if I am involved in an accident that the Church neither encourages nor discourages legal action from potentially liable or responsible third parties. I agree
to reimburse the Church for expenses paid on my behalf in the event a settlement is reached or when a liable party makes payments.

I Accept I Do Not Accept

© 2022 by Intellectual Reserve, Inc. All rights reserved.

Privacy Agreements
First Name (middle) Last Name (Legal Name) (suffix) Record number Date of birth (Age) Gender

Medical Privacy Notice

Service missionaries are responsible for their own healthcare and for all health and dental insurance and expenses. This Medical Privacy Notice will apply only if I am
called to serve a proselyting mission. For more information about how the Church protects the health information of service missionaries, please see the Church's Global
Data Privacy Policy.

Deseret Mutual Benefit Administrators (DMBA), through its Missionary Medical Department, helps to coordinate and administer missionary health care for proselyting
missionaries. DMBA is a not-for-profit Church-affiliated entity that has been assigned by the Church's Missionary Department. The United States government has enacted
privacy laws and regulations with which DMBA must comply. One of the requirements is to provide you with a Notice of Privacy Practices explaining how your health
information will be used and disclosed.
1. Understanding Your Health Record/Information
Each time you visit a hospital, physician, or other health-care provider, a record of your visit is made. Typically, this record contains your symptoms, examination and test
results, diagnoses, treatment, and a plan for future care or treatment. It may also contain correspondence and other administrative documents.

Protected health information (or "PHI") is any personally identifying information which when linked to health data could be used to identify an individual. This information
may be stored or transmitted in any form (for example, paper, electronic, verbal, etc.). All of this information, often referred to as your medical records, serve as a:

Basis for planning your care and treatment

Means of communication among the many health professionals involved in your care
Legal document describing the care you received
Means by which you or a third-party payer can verify that services billed were actually provided
Tool in educating health professionals
Source of data for medical research
Source of information for public health officials charged with improving the health of the nation
Tool to assess and monitor the health care being provided and the outcomes achieved

2. Your Health information Rights

With respect to that portion of your health record held by Deseret Mutual, you have the right to:

Inspect and obtain a copy of your medical record

Amend your medical record
Request a restriction on certain uses and disclosures of your PHI
Obtain an accounting of disclosures of your PHI (other than for purposes of treatment, payment, and health care operations)
Request communications of your PHI by alternative means or at alternative locations
Revoke your authorization to use or disclose PHI except to the extent that action has already been taken

3. Our Responsibilities
Deseret Mutual is required to:

Maintain the privacy of your PHI

Provide you with notice of our legal duties and privacy practices regarding information we collect and maintain about you
Abide by the terms of this notice
Notify you if we are unable to agree to a requested restriction
Accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations

We will not use or disclose your PHI without your authorization, except for treatment, payment or health-care operations, or as provided by law.

We reserve the right to change our practices and make the new provisions effective for all PHI we maintain. If we do so, we will notify you of the changes in writing.
4. For More Information or to Report a Problem
If you have any questions or if you would like additional information, you may contact Deseret Mutual's Compliance Officer by telephone (1-801-578-5600 or
1-800-777-3622), by mail (PO Box 45730, Salt Lake City, UT 84145) or by fax (1-801-578-5906).

If you believe your privacy rights have been violated, you can file a complaint with Deseret Mutual's Compliance Officer, or with the United States Department of Health
and Human Services, Office for Civil Rights (OCR). Complaints must be in writing and can be filed either by mail or electronically. OCR will provide further information on
its Web site about how to file a complaint (www.hhs.gov/ocr/hipaa). Please note that there will be no retaliation for filing a complaint.
5. Uses or Disclosures for Treatment, Payment, and Health Care Operations

Treatment, Payment, and Health Operations: We may use your PHI for treatment, payment, and health care operations. For example, treatment information
obtained by a nurse, physician, or other member of your health care team will be recorded in your record and used to determine the course of treatment that
should work best for you. For payment, a bill may be sent to you or a third party payer. For health care operations, we may use your health care information to
study ways to improve utilization or reduce health care costs.

6. Uses or Disclosures Permitted or Required by Law

United States Food and Drug Administration (FDA): We may disclose to the FDA PHI relative to adverse events with respect to food, supplements, product and
product defects, or post-marketing surveillance information to enable product recalls, repairs, or replacement.
Public Health: As required by law, we may disclose your PHI to public health or legal authorities charged with preventing or controlling disease, injury, or
disability.
Correctional Institution: If you become an inmate of a correctional institution, we may disclose to the institution or agents thereof PHI necessary for your health
and for the health and safety of others.
Law Enforcement or Judicial Proceedings: We may disclose certain PHI for law enforcement purposes as required by law or in response to valid subpoena.

© 2022 by Intellectual Reserve, Inc. All rights reserved.

Privacy Agreements
First Name (middle) Last Name (Legal Name) (suffix) Record number Date of birth (Age) Gender

Authorization to Disclose Protected Health Information

Who Can Release the Information:

1. The Church and its affiliated entities, including The Church of Jesus Christ of Latter-day Saints Family Services
(Family Services) and, if I am called to serve a proselyting mission, Deseret Mutual Benefit Administrators (DMBA)
and DMBA's business associates.
2. Any and all other healthcare providers and/or facilities (including mental health professionals) who have treated me
before or after this authorization.

Who Can Receive Information:

1. Representatives and employees of the Missionary Department and the Risk Management Division of The Church
of Jesus Christ of Latter-day Saints.
2. General Authorities of The Church of Jesus Christ of Latter-day Saints
3. My home unit priesthood leaders (such as the bishop and stake president) and clerks who may help my local
priesthood leaders (such as ward and stake clerks)
4. My mission leadership couple (for proselyting missionaries). This includes my mission president, historic site
president, temple president, or visitors’ center director and spouse, depending on my assignment
5. Individuals serving on the Mission Health Council (for proselyting missionaries)
6. DMBA, including its Missionary Medical Department (for proselyting missionaries)
7. Missionary Training Center personnel (for proselyting missionaries)
8. Any healthcare providers who treat me in connection with my missionary service, including Family Services or BYU
Student Health Center personnel.
9. Representatives and employees of the Human Resource Department of The Church of Jesus Christ of Latter-day
Saints (for service missionaries)
10. Service mission leaders and coordinators (for service missionaries)
11. To the extent reasonably necessary to manage my missionary service, charities or civic organizations where I am
assigned (for service missionaries)

I authorize the release of my medical information to the following individuals:

Name of Individual Relationship

The Information to Be Released:

My protected health information (PHI). PHI is individually identifiable information about an individual's past, present, or future physical or mental health that is maintained
or transmitted by a healthcare provider or health plan. PHI includes, but is not limited to, medical records, symptoms, diagnoses, treatments, prognosis, lab results,
medications, and information about insurance, claims and payment.

The Purpose for Releasing the Information:

For the overall evaluation of my health and fitness to serve as a missionary, to coordinate and manage my missionary assignments, and if I am called to serve a
proselyting mission for the management and administration of my health care while serving as a missionary for The Church of Jesus Christ of Latter-day Saints.

Expiration Date:

This authorization is valid from the date of execution until 12 months after I am released from my mission, unless revoked in writing before that time. I may revoke this
authorization by writing to DMBA, Attention: Missionary Medical Department, P.O. Box 45730, Salt Lake City, Utah 84145 (for proselyting missionaries) or to the Church
Data Privacy Office at [email protected] (for service missionaries). Revocation becomes effective only after it is received by DMBA or the
Church Data Privacy Office, and the revocation will not apply to use and/or disclosure of PHI that occurs before the written revocation is received.

I certify that the above information is true and complete. I have a right to receive a copy of this authorization. I may revoke this authorization by writing to Deseret Mutual
Benefit Administrators, Attention: Missionary Medical Division, PO Box 45730, Salt Lake City, UT 84145-0730. Revocation will be valid only for future acts and will not be
valid for any action prior to receiving my revocation. Any information used or disclosed pursuant to this authorization may be subject to redisclosure and may, therefore,
no longer be protected by privacy regulations.

If I am called to serve a proselyting mission, my treatment, payment, enrollment, or eligibility for applicable medical care will not be conditioned upon my providing this
authorization except as may otherwise be permitted by applicable law. However, I understand and agree that my refusal to sign or my revocation of this authorization may
affect my eligibility to serve or continue serving as a missionary for The Church of Jesus Christ of Latter-day Saints.

I Accept I Do Not Accept

Candidate's Signature Date

© 2022 by Intellectual Reserve, Inc. All rights reserved.

Privacy Agreements
First Name (middle) Last Name (Legal Name) (suffix) Record number Date of birth (Age) Gender

Authorization for Use and Disclosure of Psychotherapy Notes

Who Can Release the Information:

1. The Church and its affiliated entities, including The Church of Jesus Christ of Latter-day Saints Family Services
(Family Services) and, if I am called to serve a proselyting mission, Deseret Mutual Benefit Administrators (DMBA)
and DMBA's business associates.
2. Any and all other healthcare providers and/or facilities (including mental health professionals) who have treated me
before or after this authorization.

Who Can Receive Information:

1. Representatives and employees of the Missionary Department and the Risk Management Division of The Church
of Jesus Christ of Latter-day Saints.
2. General Authorities of The Church of Jesus Christ of Latter-day Saints
3. My home unit priesthood leaders (such as the bishop and stake president) and clerks who may help my local
priesthood leaders (such as ward and stake clerks)
4. My mission leadership couple (for proselyting missionaries). This includes my mission president, historic site
president, temple president, or visitors’ center director and spouse, depending on my assignment
5. Individuals serving on the Mission Health Council (for proselyting missionaries)
6. DMBA, including its Missionary Medical Department (for proselyting missionaries)
7. Missionary Training Center personnel (for proselyting missionaries)
8. Any healthcare providers who treat me in connection with my missionary service, including Family Services or BYU
Student Health Center personnel.
9. Representatives and employees of the Human Resource Department of The Church of Jesus Christ of Latter-day
Saints (for service missionaries)
10. Service mission leaders and coordinators (for service missionaries)
11. To the extent reasonably necessary to manage my missionary service, charities or civic organizations where I am
assigned (for service missionaries)

The individuals listed below will also have access to your psychotherapy notes
Name of Individual Relationship

The Information to Be Released:

My psychotherapy notes, including notes recorded in any medium by a mental health professional that document or analyze conversations from private, group, joint, or
family counseling sessions and that are separated from the rest of my medical record.

The Purpose for Releasing the Information:

For the overall evaluation of my health and fitness to serve as a missionary, to coordinate and manage my missionary assignments, and if I am called to serve a
proselyting mission for the management and administration of my health care while serving as a missionary for The Church of Jesus Christ of Latter-day Saints.

Expiration Date:

This authorization is valid from the date of execution until 12 months after I am released from my mission, unless revoked in writing before that time. I may revoke this
authorization by writing to DMBA, Attention: Missionary Medical Department, P.O. Box 45730, Salt Lake City, Utah 84145 (for proselyting missionaries) or to the Church
Data Privacy Office at [email protected] (for service missionaries). Revocation becomes effective only after it is received by DMBA or the
Church Data Privacy Office, and the revocation will not apply to use and/or disclosure of PHI that occurs before the written revocation is received.

I certify that the above information is true and complete. I have a right to receive a copy of this authorization. I may revoke this authorization by writing to Deseret Mutual
Benefit Administrators, Attention: Missionary Medical Division, PO Box 45730, Salt Lake City, UT 84145-0730. Revocation will be valid only for future acts and will not be
valid for any action prior to receiving my revocation. Any information used or disclosed pursuant to this authorization may be subject to redisclosure and may, therefore,
no longer be protected by privacy regulations.

If I am called to serve a proselyting mission, my treatment, payment, enrollment, or eligibility for applicable medical care will not be conditioned upon my providing this
authorization except as may otherwise be permitted by applicable law. However, I understand and agree that my refusal to sign or my revocation of this authorization may
affect my eligibility to serve or continue serving as a missionary for The Church of Jesus Christ of Latter-day Saints.

I Accept I Do Not Accept

Candidate's Signature Date

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