2019 IAMM VOLUNTEER REQUEST FORM
INTERNATIONAL-AMERICAN MEDICAL MISSION
Please select the mission(s) with which you are interested in volunteering:
January 29 -- February 9, 2019 BOTH the SANTO DOMINGO and BELIZE CITY Missions
January 29 -- February 2, 2019 in SANTO DOMINGO, Dominican Republic ONLY
February 3 -- February 9, 2019 in BELIZE CITY, Belize ONLY
June 22 -- June 27, 2019 in FORT WORTH, Texas
July 26 -- August 1, 2019 in SPANISH TOWN, Jamaica
I cannot physically attend a mission, but I would like to be added to the IAMM database.
Last Name, First Name
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
Name exactly as it appears on your passport
Passport Expiration Date
MEDICAL TEAM MISSION SERVICE
Please complete this section if you want to be part of the medical team; if approved, you will need to submit copies of your degree(s) and current licenses by October 1, 2017.
I have the following MEDICAL credentials:
MEDICAL Area of Specialization
Hospital or Medical Organization Affiliation:
Number of years in MEDICAL practice:
NON-MEDICAL MISSION SERVICE
Anyone who is NOT a pharmacist, medical or dental provider or nurse or nurse practitioner is asked to complete this section.
I am not a doctor, dentist, or pharmacist, 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)
Address (Please also provide the city, state, and zipcode.)
Emergency Contact Telephone #:
I understand that I am submitting this Volunteer Request Form by September 1, 2018, AND that if I am approved to be part of one or several of the the 2019 IAMM Teams, I am expected to submit my $250 non-refundable deposit payable to IAMM by or before October 1, 2018.
Send me a copy of my responses.
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