2020 IAMM VOLUNTEER REQUEST FORM for the Dominican Republic
Please complete this form to indicate your interest in being part of the IAMM Team doing mission work in the DOMINICAN REPUBLIC from Monday, February 17, 2020, through Friday, February 28, 2020.
Email address *
INTERNATIONAL-AMERICAN MEDICAL MISSION
GENERAL INFORMATION
Please select the mission(s) with which you are interested in volunteering: *
Last Name *
Your answer
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 *
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, 2019.
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 licensed pharmacist, medical or dental provider or nurse or nurse practitioner is asked to complete this section of the Volunteer Request Form
I am not a doctor, dentist, pharmacist, or nurse 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
Emergency Contact Telephone #:
Your answer
I understand that I am submitting this Volunteer AND that if I am approved to be part of one or more of the 2020 IAMM Teams, I am expected to submit my $250 non-refundable DEPOSIT payable to IAMM by (or before) November 15th, 2019. *
Required
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