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Medical Mission Interest Form

Program Selection

Please select the upcoming Medical Mission program that you are interested in. If unsure, please select 'General Interest'.

Personal Information

Email communication is critical for team planning. Please provide the best email address to reach you.

Do you have a passport that is valid for AT LEAST SIX MONTHS BEYOND the Medical Mission dates?
Have you received your full COVID-19 vaccination? (Two shots of Pfizer/Modern or single J&J, PLUS booster)
If you speak more than one language, including American Sign Language, please indicate below

Please list an medical licenses and certifications you actively hold (i.e. RN, CNA, MD, etc.)

Where do you study and what is your area of study?

Additional Information

What skills will you bring to the Mission (i.e. medical training & experience, teaching, travel experience, etc.)? Please describe in < 100 words.