Ambulance - Madre y Niño

Basic Information

Name *

Name you commonly go by:

Email Address *

Phone *

Street Address *

Apartment, suite, etc.

City

State/Province

ZIP / Postal Code

Country

Date of Birth

Month

Day

Year

GenderMaleFemaleOther (please specify)

Gender Identity:

Employment Information

Current Employer

Job Title

Medical Credentials

Professional Medical Designation:

If you selected "None" or "Other," please describe:

Professional (Medical) License Type

Professional (Medical) License Number

License Expiration Date

Licensed OR professionals, please provide:

Surgical Gown Size

Surgical Glove Size

Latex Allergy?

Education

Are you a student or resident?YesNo

Current School/University

Degree/Program/Specialty

Projected Completion Date

References

Professional Reference Name *

Relationship

Contact Email

Contact Phone

Mission Trip Information

Week(s) you will be attending: *Both weeks (August 3-18)Week 1 only (August 3-9)Week 2 only (August 9-18)

Passport Number *

Passport Expiration Date *

Issuing Country *

Name(s) of anyone traveling with you

T-Shirt Size *

Spanish Proficiency *

Health Information

Please provide health and dietary information that we should be aware of.

Medical Conditions

Current Medications

Emergency Contact Information

Emergency Contact Name *

Relationship

Phone *

Email Address

Physician's Name *

Physician's Phone *

Payment Information and Agreements

After your application is submitted and accepted, you will receive an email with further instructions. Please check the boxes below to acknowledge that you have read the payment information and agreements.

Mission Trip Participant Fee Total: $1,200 (two weeks) or $800 (one week)

Trip fees cover in-country transportation, meals and lodging, language translator services, in-country travel insurance, and your medical mission team t-shirt. Mission trip payments also contribute in part to the cost of medical and surgical supplies (including patient medications) used during the service week.

All trip fee payments are non-refundable, but can be held in credit for a future trip for up to two years (if a volunteer needs to cancel).

Initial Trip Participant Deposit: $200 non-refundable

Your spot on the team will be confirmed when the deposit is received. The trip deposit will be allocated toward the total trip fee.

Payment Deadline

Trip fee payment in full is due 30 days prior to your departure date. Your mission trip participant packet (including your team t-shirt) will be sent to you upon receipt of total trip payment.

Waiver & Release

Mission Trip Participant Code of Conduct

Mission Trip Participant Public Disclosure Policy

Travel Information

Designated Team Flights:

Mission trip participants are required to purchase their own air travel to and from Guatemala, and designated team flight information will be posted by your Team Leader 3 months prior to the trip start date.

Do not purchase airline tickets until your spot on the team is confirmed and you have reviewed the designated flight information. It is required to arrive on the designated team flights (or prior approval from the Team Leader for alternate flights), as in-country transportation and transfer site is coordinated for the entire group. If you arrive separately from the group, your transfer will be a personal expense.

Preparing For Your Mission Team Trip

After your spot on the trip is confirmed, your Team Leader will send you Travel Guidelines & Preparation information specific to the mission location. This information will include recommendations on travel vaccinations and packing lists.

We can't wait to see you in Guatemala! Thank you!

Additional Comments:

Would you like to pay for all or part of your trip fees now? *Make a nonrefundable deposit: $200Pay in full for 1 week: $800Pay in full for 2 weeks: $1,200I will pay my trip fees later

Total:

$

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Volunteer Application

Basic Information

General donation form