MISSION MEMBER INFORMATION SHEET

(FAX BACK TO 860-489-9017)

NAME________________________________________________________

TITLE______________________________SCHOOL____________YR____

ADDRESS______________________________________________________

______________________________________________________

PHONE__________________________CELL________________________

FAX_____________________________E-MAIL_________________________

SPEAK SPANISH YES/NO

ARRIVAL DAY_________________FLIGHT #____________TIME__________

TAKING BUS FROM AIRPORT TO SJDS YES/NO

DEPARTURE DAY______________FLIGHT #____________TIME___________

TAKING BUS FROM SJDS TO AIRPORT YES/NO

T-SHIRT SIZE_____________

I WILL ROOM WITH__________________________________/NO ONE

I AM STAYING AT ____________________________________________ 

I have read, understand and agree to all the terms and conditions as stated in the VOSH-CT Protocol 2008. I understand that I am participating in this mission to provide services to those in need, and that some patients choose to pay approximately 25 cents for services rendered and others will pay nothing in accordance with local customs and culture. All patients will be seen, regardless of ability to pay. I agree to accept the cultural and clinical procedures of this mission and further agree at all times to respect and avoid public/personal criticism of the mission leaders, other mission members and host community leaders, doctors and volunteers.

Signature_______________________________________ Date_____________

Return to Homepage