IAMM Pharmacy VOLUNTEER REQUEST FORM: San Pedro de Macorís in the Dominican Republic July 25th

IAMM VOLUNTEER REQUEST FORM: Cap Haitien, Haiti - January 27th-February 6th, 2027

This form is open for those interested in being part of the international mission in Haiti
All fields marked with * are required and must be filled.
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.Format: (000) 000-0000.
Do you receive and respond to texts on your mobile phone?
Alternate Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Please Select the dates you are attending
Have you served on previous international (or national) missions with IAMM?
T-Shirt Size
- Do you have a current valid passport.
- Have you applied for your passport
- Name exactly as it appears on your passport
- Input Passport Number exactly as it appears on your passport
- Passport Expiration Date
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Upload Passport
  
  Cancelof
- Name
  
  First NameLast Name
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Contact's Relationship to Volunteer
- Emergency Contact Telephone #:
  Please enter a valid phone number.Format: (000) 000-0000.
- I am volunteering as a(n):
- Submit two Headshots: 1st
- 2nd Headshot
- MEDICAL Area of Specialization
- Number of years in MEDICAL practice:
- Upload Diplomas
  
  Cancelof
- UPLOAD MEDICAL CREDENTIALS:
  
  Cancelof
- Upload letter of Good Standing medical License.
  
  Cancelof
- College (medical) transcripts.
  
  Cancelof
- Upload background check.
  
  Cancelof
- Form / Amount Payment (ALL PAYMENTS should be sent directly to Sandra Franklin. This form does not accept payments.)
  
  Payments may be made by Check / Money Order, Credit Card, Zelle (IAMMonline@gmail.com), or CashApp ($IAMMdonation). Make all Checks or 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 (IAMM). 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.
  
  I also give permission to IAMM to photograph or record me during volunteer activities. I understand that these images may be used for IAMM’s official purposes, including documentation, training, publications, social media, and promotional materials. I acknowledge that IAMM will not sell or misuse my images.
- Signature
- Should be Empty:

IAMM VOLUNTEER REQUEST FORM: Cap Haitien, Haiti - January 27th-February 6th, 2027