Mission Volunteer Form

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Chiapas, Mexico: May 12-19, 2004

Please fill out all the required information and make payment no later than 4/1/14 in order for MMM to be able to secure necessary authorizations, flight reservations, etc.

Nb. In order to complete this form, you will need 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*

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
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.*

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.*

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

Yes
Volunteer fees for MMM’s 2014 Chiapas Mission are US$580 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 (Tuesday-Saturday), 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

Mission Volunteer Form

Chiapas, Mexico: May 12-19, 2004

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