2019 IAMM VOLUNTEER REQUEST FORM
Email address *
INTERNATIONAL-AMERICAN MEDICAL MISSION
GENERAL INFORMATION
Please select the mission(s) with which you are interested in volunteering: *
Required
Last Name, First Name *
Your answer
Street Address *
Your answer
City, State & Zipcode *
Your answer
Email Address
Your answer
Mobile Phone #
Your answer
Do you receive and respond to texts on your mobile phone?
Alternate Phone #
Your answer
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
Your answer
Passport #
Your answer
Passport Expiration Date
MM
/
DD
/
YYYY
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
Your answer
Hospital or Medical Organization Affiliation:
Your answer
Number of years in MEDICAL practice:
Your answer
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:
EMERGENCY CONTACT INFORMATION
Everyone should complete this section.
Full Name of Emergency Contact:
Your answer
Contact's Relationship to Volunteer
Address (Please also provide the city, state, and zipcode.)
Your answer
Emergency Contact Telephone #:
Your answer
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. *
Required
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