2020 IAMM VOLUNTEER REQUEST FORM for BELIZE
Please complete this form to indicate your interest in being part of the IAMM Team doing mission work in BELIZE from July 31, 2020 -- August 8, 2020
INTERNATIONAL-AMERICAN MEDICAL MISSION
City, State & Zipcode
Mobile Phone #
Do you receive and respond to texts on your mobile phone?
Alternate Phone #
PASSPORT & MISSION TRAVEL INFORMATION
Have you served on previous international (or national) missions with IAMM?
I have a current valid passport
Passport Expiration Date
MEDICAL TEAM MISSION SERVICE
Please complete this section if you MEDICAL and want to be part of the medical team; if approved, you will need to submit copies of your degree(s) and current licenses by February 29, 2020.
I have the following MEDICAL credentials:
Medical Doctor, Adults
Medical Doctor, Pediatrics
Medical Doctor, Ob/Gyn
MEDICAL Area of Specialization
Hospital or Medical Organization Affiliation:
Number of years in MEDICAL practice:
NON-MEDICAL MISSION SERVICE
Anyone who is NOT a licensed pharmacist, medical or dental provider or nurse or nurse practitioner is asked to complete this section of the Volunteer Request Form
I am not a doctor, dentist, pharmacist, or nurse however I would like to use the following skills and/or resources as a volunteer during the upcoming mission trip in the DR:
Administative Support -- General
Administrative Support -- Data Entry
Medical Support (CNA, Medical Assistant, etc.)
Clinic Set-up & Break-down
EMERGENCY CONTACT INFORMATION
Everyone should complete this section.
Full Name of Emergency Contact:
Contact's Relationship to Volunteer
Parent (or Grandparent)
Child (or Grandchild)
Emergency Contact Telephone #:
I understand that I am submitting this Volunteer AND that if I am approved to be part of one or more of the 2020 IAMM Teams, I am expected to submit my $250 non-refundable DEPOSIT payable to IAMM by (or before) March 1, 2020.
Send me a copy of my responses.
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