Medical Mission Ecuador Volunteer Application 2020
We will be accepting applications through October 1st, 2019. Not all who apply will be able to attend. We will assess our needs and match up the volunteers that fit those needs to best serve our patients.
ALL VOLUNTEERS NEED TO FILL OUT AN APPLICATION EACH YEAR. Must be over 18 years of age.

If you have not previously volunteered or have no volunteer member for reference, you MUST fill out the section telling us about yourself as well as email us to describe your interest, qualifications, and how you anticipate you can be of help to the mission. You also need to contact us by email with an introductory letter / email describing your qualifications and potential contributions. Applications lacking this information will be discarded. Thank you.
Last Name *
Your answer
First Name *
Your answer
Most Advance Degree *
No periods please. (Ex: BA, MS, BSN, MD, or PhD, etc...)
Your answer
Email Address: *
Your answer
Specialty *
Preferred Mailing address Street: *
Your answer
Preferred Mailing address Street 2 (if needed):
Your answer
Preferred Mailing address City *
Your answer
Preferred Mailing address State: *
(2 letter abbreviation please)
Your answer
Preferred Mailing address Zip Code: *
(5 digit zip code)
Your answer
Preferred Contact Phone number: *
(xxx-xxx-xxxx format please)
Your answer
Can you receive texts at that phone number? *
(In case of need to contact you by text message)
Emergency Contact Name: *
Your answer
Emergency Contact Address Phone: *
(xxx-xxx-xxxx format please)
Your answer
Emergency Contact Relationship to you: *
Your answer
Passport Number: *
This information is needed for our hotel in Ecuador. If you do not have it with you, you will need to provide it eventually. When you look it up, please put it down in your phone so you will always have it available.
Your answer
Passport Expiration Date: *
Please put in the date so we can be sure there are no expiration problems. The Eric Miller Rule. Your passport must be valid for 6 months from the start of your travel to Ecuador. This is a USA CBP rule, you will not be allowed to leave the US without this.
MM
/
DD
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Passport Country *
Prior Medical Missions Attended: *
Reference Person: *
Please type in any references you have of someone who is associated with the Mission trip or indicate "None" If "None" you must contact us with information about your interest, qualifications, ways you can contribute.
Your answer
Health Status: *
Any Activities unable to perform on the mission due to medical issues? *
Special Dietary Needs *
Any other information we need to know or you wish to provide?
Your answer
Please indicate below if you have read and accept the terms of the MME Waiver *
If you have not read it, it is located here: http://www.medicalmissionecuador.org/#!waiver/c108o
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