Nepal 2015

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Nepal Earthquake Relief 2015

Please fill out all the required information [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 submission of this form shall constitute your legal acceptance of all terms and conditions referred to herein.
2015 – Nepal
2015 Nepal Form Fill

Yes
Briefly describe how you discovered Mammoth Medical Missions and if you were referred by someone, who referred you?*
Full Name (as it appears on passport)*

First Name Last Name
E-mail*
When can you leave? How long can you stay? What airports can you depart from?
Mobile 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 – Note: this can be done simply using your smart phone and emailing the image to yourself then attaching below from your computer, or text image to 760-709-0675 PLEASE make sure no glare of flash obscures any part of the data on the passport.
Primary Specialty*
Secondary Specialty
Professional License Type*
Other?
Professional License Number
State
References, please list at least three professional references
Briefly describe your foreign language proficiency
I have reviewed the CDC’s Health Information for Travelers to Nepal 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.
T-shirt size*
Emergency Contact*

First Name Last Name
Emergency Contact E-mail*
Emergency Contact Phone*

–Area Code Phone Number
MMM CODE OF CONDUCT:

http://www.mammothmedicalmissions.org/conduct-media-confidentiality/
I have read and agree to MMM’s Code of Conduct, Confidentiality and Media Policy*

Yes
TERMS & CONDITIONS:

http://www.mammothmedicalmissions.org/mission-volunteer-terms/
I have read and agree to all Terms & Conditions*

Yes
Please help me set up an individual fundraiser on Crowdrise to help me raise money to cover my trip fees

Yes
No

Nepal 2015

Nepal Earthquake Relief 2015

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