Chiapas 2015 Registration

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Chiapas, Mexico: May 2015

Please fill out all the required information and make payment no later than 1/9/15 [NOTE: In order to complete this form, you will need current digital images of your passport and relevant professional license (jpeg or pdf files no larger than 1mb each). Your payment upon submission of this form shall constitute your legal acceptance of all terms and conditions referred to herein.]
Full Name (as it appears on passport) *

First Name Last Name
E-mail *
Primary Phone *

– Area Code Phone Number
Secondary Phone

– Area Code Phone Number
Address *

Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Country
Birth Date*

Month Day Year

Place of Birth *
Citizenship*
Passport Number *
Passport Expiration*

Month Day Year
Primary Specialty *
Secondary Specialty
Professional License Type*
Other?
Professional License Number
State

I have been invited to volunteer and would like to participate in the following mission segment(s):
Medical-Skills Training Initiative (Week One: May 4-8)

Mass Casualty/Disaster Medicine Seminar (May 10)

Routine/Elective Surgical Segment (Week Two: May 11-15)
Briefly describe your proficiency in Spanish and/or indigenous Mayan dialects *
I have reviewed the CDC’s Health Information for Travelers to Mexico and other travel health information sources and take full responsibility for my own vaccinations, medicines and safe travel practices. *

Yes
I agree to purchase travel insurance with adequate emergency medical evacuation coverage, and to furnish the details of said coverage to MMM’s Logistical Coordinator. All emergency costs not covered by travel insurance will be borne by individual, not MMM. *

Yes
I understand that serving in the field with Mammoth Medical Missions is likely to involve working and living in relatively austere conditions, including but not limited to cooking and sleeping outdoors, traveling overland with heavy loads, lack of access to electricity or other conveniences, and general exposure to weather and conditions. *

Yes
That said, I have the following dietary and/or physical restrictions and/or preferences.
Emergency Contact *

First Name Last Name
Emergency Contact Phone *

– Area Code Phone Number
Emergency Contact E-mail *
Roommate/tentmate request
T-shirt size *
I have read and agree to MMM’s Code of Conduct, Confidentiality and Media Policy: http://www.mammothmedicalmissions.org/conduct-media-confidentiality/ *
Yes
I have read and agree to all Terms & Conditions: http://www.mammothmedicalmissions.org/mission-volunteer-terms/ *

Yes
Please help me set up an individual fundraiser on Crowdrise to help me raise money to cover my trip fees: https://www.crowdrise.com/mmmchiapas

Yes No
Volunteer fees for MMM’s 2015 Chiapas Mission are US$600 per person, which sum shall include roundtrip airfare from LAX to Tuxtla Gutierrez (TGZ), roundtrip ground transportation from TGZ to San Andrés Larraínzar, some camping equipment and supplies (as necessary), meals during work days, administrative and membership fees, plus two nights hotel accommodations in San Cristóbal de las Casas. Payment can be made by PayPal or credit card on the following screen; your payment and submission of this form shall constitute your acceptance of all terms and conditions contained or referred to herein. Press “Submit” to continue.
Mission Volunteer Fees (Paypal)

USD Mission Participant/Travel Fees

Chiapas 2015 Registration

Chiapas, Mexico: May 2015

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