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Medical Mission Interest Form
Program Selection
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Please select the upcoming Medical Mission that you are interested in.
Personal Information
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First Name
Last Name
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Email communication is critical for team planning. Please provide the best email address to reach you.
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Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code
Country
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Do you have a passport that is valid for AT LEAST SIX MONTHS BEYOND the Medical Mission dates?
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Have you received your full COVID-19 vaccination? (Two shots of Pfizer/Modern or single J&J, PLUS booster)
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If you speak more than one language, including American Sign Language, please indicate below
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Please list an medical licenses and certifications you actively hold (i.e. RN, CNA, MD, etc.)
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Where do you study and what is your area of study?
Additional Information
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What skills will you bring to the Mission (i.e. medical training & experience, teaching, travel experience, etc.)? Please describe in < 100 words.