CASTROVIRREYNA (HUANCAVELICA) PERU

OCTOBER ____ to OCTOBER ____, 201____ A Medical Mission Sponsored by Soul of the Peruvian Andes, Inc.

Volunteer Application

Last Name Address Home Phone Email Address: Occupation:

First Name

Middle Name

Work Phone

Cell Phone DOB:

MD/Dentist Specialty:

RN Specialty:

ALL MDs, NURSES & DENTIST ARE REQUIRED TO SUBMIT COPY OF: DIPLOMA, CURRENT MEDICAL LICENSE, PASSPORT AND CV
Do you speak Spanish? Yes No or medical versed

If yes, please state level of fluency: conversational

PLEDGE: I will work from October ______ through October ______, 201______ I will travel with:

I will behave professionally and ethically at all times, acknowledging that if I break this pledge my participation in the Mission will be terminated.

Signature In case of emergency notify:

Date Phone/Email:

Please state your reason why you would like to participate in this mission:

Questions or Comments:

Please return this form by mail to: C/O Dr. Gabriel Garcia 139-76 35 th Avenue, Suite 1B, Flushing, NY 11354 or Email it to: LREBATTA@AOL.COM PLEASE ADD A SHORT BIO FOR OUR FILES