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January 19th Clinic Sign Up Form
Hello everybody!
We will be holding our next clinic trip on Saturday, January 19. Members who will be helping out on the Jan 12th Clean Up Trip are guaranteed to come on this trip. Drivers and fluent Spanish speakers will also be given priority.
We will meet at the corner of Myers's and Gilman at 7AM and we will get back at UCSD at the same location around 8PM (depends on traffic). You must be a paid member and have a US passport to attend. Membership fee is $25 and can pay at pre-clinic meeting.. Clinic fee is $30 (drivers do not pay). All selected members must attend pre-clinic meeting on Friday January 18th in the evening.
Please sign up if you are interested in attending.
Look forward to a great clinic!
Clinic Coordinator Flying Samaritans
Kiana Pham
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First Name
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Your answer
Last Name
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Your answer
Email Address
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Your answer
Phone Number
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Your answer
DId you attend January 12th Clean Up trip
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Yes
No
Would you be able to drive to the Clinic on January 19?
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(gas money is reimbursed)
Yes
No
If you are able to drive, how many people, besides yourself, does your vehicle hold?
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2
3
4
5
Other:
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If you are able to drive please provide your car's make, model, licence plate number
this information is required for transportation of medication into Mexcio
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Spanish Fluency
*
(0-Understand No Spanish, 5-Native Speaker)
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1
2
3
4
5
Emergency Contact
*
(name and phone number)
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Membership Status
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(members have paid club dues)
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Previous Clinic Trips
(how many clinics have you attended in the past)
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Comments or Concerns
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