March 10th Clinic Sign Up Form
Hello everybody!

SDSU will be holding their clinic trip on Saturday, March 10th. They've invited us to join them on this trip. We are sending one car full of UCSD students to visit their clinic. Their clinic has a great connection with the community, their trips are very fun, and members who are selected go to on this trip will benefit from gaining more diverse experience with different low-resource interventions.

If you have attended at least 2 events and have a valid US passport we encourage you to apply. Drivers will also be given priority.

You will receive notification by Sunday night, March 4 whether or not you have been selected.

Look forward to a great clinic!

Flying Sams Clinic Coordinator

First Name *
Your answer
Last Name *
Your answer
Email Address *
Your answer
Phone Number *
Your answer
Event Requirement *
Would you be able to drive to the Clinic on March 10? *
(gas money is reimbursed)
If you are able to drive, how many people, besides yourself, does your vehicle hold?
If you are able to drive please provide your car's make, model, licence plate number
this information is required for transportation of medication into Mexcio
Your answer
Spanish Fluency *
(0-Understand No Spanish, 5-Native Speaker)
Emergency Contact *
(name and phone number)
Your answer
Membership Status *
(members have paid club dues)
Previous Clinic Trips
(how many clinics have you attended in the past)
Your answer
Comments or Concerns
Your answer
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service