Name *

First Name

Last Name

Phone *

Country

(###)

###

####

Professional Title *

Physician

Nurse

PA/NP

Resp Therapist

Dentist

Medical Student

Other

Former International Medicine Experience *

Yes

No

Are you willing to prepare and teach a class and/or give lectures in your field? *

Yes

No

Are you comfortable speaking in front of large groups? *

Yes

No

Are you able to operate in rural environments with limited resources? *

Yes

No

Are you willing to carry and/or obtain supplies if needed? *

Yes

No

Are you willing to fundraise for the trip? *

Yes

No

Are you available for 2 weeks or more? *

Yes

No