MAP Ambassadors - Expression of Interest
For anyone thinking of collaborating with MAP to bring material aid to hospitals and clinics in under-resourced communities overseas, please fill in the form below and we will be in contact with you shortly.

In order for us to work effectively with you. We request that you fill in this form as soon as you have confirmed your elective.
Email address *
1. What is your full name? *
2. What is the Melbourne-based organisation you are associated with? eg. TeamMED, PANGEA
3. Which MAP Project Officer has been your point of contact? *
4. Which of the following best describes you? *
5. If you are a student, what university are you currently studying at?
6. Where will you be travelling? *
7. What is the name of the health organisation which you will be visiting? *
8. Please briefly describe what the focus of your trip is eg. Maternal health, health promotion
9. What are the contact details (name, email, phone number and address) of your liaison overseas? *
10. What is your approximate date of departure? *
11. Will you be travelling with other passengers willing to bring equipment over? *
12. How many extra kg of luggage will you (and/or your group) be able to carry in your checked in luggage (please be as realistic as possible)? *
13. Is there anything else you'd like us to know? *
A copy of your responses will be emailed to the address you provided.
Never submit passwords through Google Forms.
This form was created inside of Melbourne University Health Initiative Inc..