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Medical Mission Interest Form
Program Selection
Upcoming Medical Missions
*
Please select the upcoming Medical Mission that you are interested in.
select one
May-June 2023: Kenya
August 2023: Liberia
September 2023: Bangladesh
October 2023: Nepal
November 2023: Guatemala
January 2024: Uganda
Personal Information
Full Name
*
First Name
Last Name
Email
*
Email communication is critical for team planning. Please provide the best email address to reach you.
Verify Email
*
Phone Number
*
Address
*
Address Line 1
Address Line 2
City
City
State
State/Province
ZIP/Postal Code
Country
Passport
*
Do you have a passport that is valid for AT LEAST SIX MONTHS BEYOND the Medical Mission dates?
Yes
No
COVID-19 Vaccination
*
Have you received your full COVID-19 vaccination? (Two shots of Pfizer/Modern or single J&J, PLUS booster)
Yes
No
Do you speak more than one language?
*
If you speak more than one language, including American Sign Language, please indicate below
Yes
No
Language:
*
Fluency
*
Fluent
Minimal
Conversational
Read
Write
Employment
*
Full-time
Part-time
Student
Retired
Medical License/Certification
*
Please list an medical licenses and certifications you actively hold (i.e. RN, CNA, MD, etc.)
School & Area of Study
*
Where do you study and what is your area of study?
Additional Information
Applicable Skills
*
What skills will you bring to the Mission (i.e. medical training & experience, teaching, travel experience, etc.)? Please describe in < 100 words.
