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.

Email address *
INTERNATIONAL-AMERICAN MEDICAL MISSION
GENERAL INFORMATION
Please select the remaining 2019 mission(s) for 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 December 21, 2018
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 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. *
Required
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