2019 IAMM VOLUNTEER REQUEST FORM: Fort Worth, Texas or Spanish Town, Jamaica
This form is open for those interested in being part of EITHER the 2019 national health fair in Fort Worth, Texas OR the international mission in Spanish Town in Jamaica
NOTE: The 2019 missions teams to both Santo Domingo and Belize City are filled.
INTERNATIONAL-AMERICAN MEDICAL MISSION
Please select the remaining 2019 mission(s) for which you are interested in volunteering:
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 December 21, 2018
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 for Fort Worth, Texas and/or Spanish Town, Jamaica AND that if I am approved to be part of one or both of the remaining 2019 IAMM Teams, I am expected to submit my $250 non-refundable deposit for the Jamaica mission payable to IAMM by Saturday, March 30, 2019.
Send me a copy of my responses.
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