2024 IAMM VOLUNTEER REQUEST FORM: Dominican Republic January 27 - 31, 2025 & February 1

2024 IAMM VOLUNTEER REQUEST FORM: Dominican Republic January 27 - 31, 2025 & February 1 - 8, 2025

This form is open for those interested in being part of the international mission in Dominican Republic
All fields marked with * are required and must be filled.
Please select the time period that you would like to volunteer for:*
Name*

First NameLast Name
Email*
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobile Number *
Please enter a valid phone number.
Do you receive and respond to texts on your mobile phone?

YesNo
Alternate Phone #
Please enter a valid phone number.
Have you served on previous international (or national) missions with IAMM?

YesNo

EMERGENCY CONTACT INFORMATION
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact's Relationship to Volunteer

SpouseParent (or Grandparent)Child (or Grandchild)Other
Emergency Contact Telephone #:
Please enter a valid phone number.

Form / Amount Payment (ALL PAYMENTS should be sent directly to Sandra Franklin. This form does accept payments.)
Form of Payment

Check / Money OrderCredit CardCash
Amount Paid: $ Date Paid:01/01/2023
Balance Due: $
Make Checks/Money orders payable to ($250 nonrefundable deposit):

International American Medical Mission:
11355 S. Halsted Street
Chicago, Illinois 60624

ATTENTION: Sandra Franklin

(773) 568-2929

ALL PAYMENTS should be sent directly to Sandra Franklin. This form does accept payments.
I acknowledge that by submitting this Volunteer Request Form, I am expressing my interest in volunteering with the International American Medical Mission. Furthermore, I understand that if my application is accepted and I become a member of the IAMM Team, I am required to submit a non-refundable deposit for the medical mission, payable to IAMM.
Signature

Clear
Should be Empty:

2024 IAMM VOLUNTEER REQUEST FORM: Dominican Republic January 27 - 31, 2025 & February 1 - 8, 2025