Member
Information Sheet 2009
(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 2009. 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_____________