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__________

DEPARTURE DAY______________FLIGHT #____________TIME___________

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 2010. 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_____________