Medical Mission Volunteer Portal

MMM Team Volunteer FormIf you’ve been invited to do so by a member of the MMM Executive Board, please fill out all of the required information below in order be entered into the MMM volunteer member roster for future Mass Casualty Team Training Seminars, and for consideration on future routine missions and emergent deployments. Please understand that submitting this form does not guarantee participation in any MMM activities, missions or deployments.

Full Name*

First Name Last Name
E-mail*
Affiliation
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
Passport Image*
Primary Specialty*
Secondary Specialty
Professional License Type*
Other?
Professional License Number
State
Professional License Image
Briefly describe your proficiency in languages other than English.*
I understand that serving in the field with Mammoth Medical Missions may 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, irregular or truncated sleep schedules, and general exposure to weather and conditions.*

Yes
I understand that if invited to serve on a mission or deployment with MMM I will be asked and expected to contribute to activities on the ground outside of my medical training, including but not limited to site clean-up, clinic construction, cooking/food preparation, transport of patients and or supplies, implementation of personal and group hygiene protocols. Some of the above activities may involve hiking greater that 1 mile with a backpack, and lifting and/or transporting heavy loads–as such, I understand that it is my responsibility to ensure that I am adequately fit to carry out these and other such tasks.*

Yes
Emergency Contact*

First Name
Last Name
Emergency Contact Phone*

–Area Code
Phone Number
Emergency Contact E-mail*
I have read and agree to MMM’s
Code of Conduct, Confidentiality and Media Policy*

Yes
I have read and agree to all
Terms & Conditions*

Yes
T-shirt size*
Enter the message as it’s shown*

Medical Mission Volunteer Portal

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