Medical Mission Ecuador Volunteer Application  2021
We will be accepting applications through October 1st, 2020. Unfortunately, not all who apply will be able to attend. We will assess our needs and match up the volunteers that fit those needs to best serve our patients. We have a limited amount of space and preference is given to medical volunteers.

ALL VOLUNTEERS NEED TO FILL OUT AN APPLICATION EACH YEAR. Must be over 18 years of age.

If you have not previously volunteered or have no volunteer member for reference, you MUST fill out the section on the application with a brief identifying note about yourself (for example: OR Scrub tech with 10 years experience in Ortho) as well as email us to describe your interest, qualifications, and how you anticipate you can be of help to the mission at medicalmissionecuador@gmail.com. Applications lacking this information will be discarded. Thank you.

Please do not make concrete plans to attend the mission until specific approval has been given via email from administration. It may take until November 2020 to determine our needs, although you may hvae confirmation long before then. This still allows 3 months of planning time. If you do not hear back from us, please reach out to medicalmissionecuador@gmail.com.  
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Last Name *
First Name *
Most Advance Degree *
No periods please. (Ex: BA, MS, BSN, MD, or PhD, etc...)
Email Address: *
Specialty *
Preferred Mailing address Street: *
Preferred Mailing address Street 2 (if needed):
Preferred Mailing address City *
Preferred Mailing address State: *
(2 letter abbreviation please)
Preferred Mailing address Zip Code: *
(5 digit zip code)
Contact Phone number: *
(xxx-xxx-xxxx format please)
Can you receive texts at that phone number? *
(In case of need to contact you by text message)
Emergency Contact Name: *
Emergency Contact Address Phone: *
(xxx-xxx-xxxx format please)
Emergency Contact Relationship to you: *
Passport Number: *
This information is needed for our hotel in Ecuador. If you do not have it with you, you will need to provide it eventually. When you look it up, please put it down in your phone so you will always have it available.
Passport Expiration Date: *
Please put in the date so we can be sure there are no expiration problems. The Eric Miller Rule. Your passport must be valid for 6 months from the start of your travel to Ecuador. This is a USA CBP rule, you will not be allowed to leave the US without this.
MM
/
DD
/
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Passport Country *
Prior Medical Missions Attended: *
Reference Person: *
Please type in any references you have of someone who is associated with the Mission trip or indicate "None" If "None" you must contact us with information about your interest, qualifications, ways you can contribute.
New volunteers: One or two notes about your ability to contribute (plus, send more descriptive intriductory email to medicalmissionecuador@gmail.com)
Health Status: *
Any Activities unable to perform on the mission due to medical issues? *
Special Dietary Needs *
Please indicate below if you have read and accept the terms of the MME Waiver *
If you have not read it, it is located here: http://www.medicalmissionecuador.org/#!waiver/c108o
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