3M Collective: Medical Mission Match Non-Profit or NGO Registration Form
What is the name of your Non-Profit or NGO?
*
Enter the legal name of your Non-Profit or NGO
What is your organization's annual budget?
*
< $1M USD
$1-3M USD
$3-5M USD
$5-10M USD
>$10M USD
How many FTE's does your organization employ?
*
1-10 FTE
20-30 FTE
30+ FTE
What is your organization's EIN?
What is your name?
*
First Name
Middle Name
Last Name
(e.g. MD)
What is your title within the organization?
Enter your role and or title within the organization.
Email
*
Enter your email
Mobile Number | WhatsApp | Telegram | Signal
*
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Country
*
What Services Does Your Organization Provide?
Select all the medical services your organization provides?
Blood Bank Services
Cath Lab (Cardiology, IR, Neuro) Services
Dialysis Services
Emergency Medicine Services
Imaging Center Advanced (CT, MRI)
Imaging Center Basic (X-Ray, Ultrasound)
Inpatient Facility (Non-ICU)
Inpatient Facility (Critical Care)
Laboratory Services
Labor and Delivery Facility
Medical Transportation Services
Outpatient Clinic Care
Operating Rooms and Surgical Suites
Pediatric Psych, PTSD Treatment
Pharmacy Services
Vaccination Services
Other
Select the non-medical services your organization provides?
Food
Clothing
Shelter
Education
Other
Describe the greatest needs for the people you serve?
Virtual Care Access and Scheduling
Is your organization interested in accessing a virtual network of medical professionals for virtual care consultation services?
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Yes
No
Does your organization have a "call calendar" for virtual care providers to be notified when they may be contacted by your organization for remote service consultations?
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Yes
No
Other Information
Signature
Submit
Submit
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