Instructions: Please fill out completely and press submit at the bottom when you are finished. US passports must not expire within 90 days of your departure from Honduras. Non US passports MUST optain a VISA. Non University emails are preferred if you check one regularly, institutional spam filters make communicating with you unpredictable.
IMPORTANT Please provide your name exactly as it appears on your Passport
First Name Middle Name
Last Name
Address
City State Zip Male Female
Date of Birth (yyyy-mm-dd)
Cell Number that you travel with Email
Passport Number Passport Expiration Date (yyyy-mm-dd)
Type of Visit Brigade Medical Redident Rotation Medical Student Rotation Nursing Long Term Other
If in Group UC VCU/Thundermist UNC Asheville John Hopkins Brown Rochester Wyoming Montana Dental Minnesota John Hopkins Kansas Wright State MAHEC Good Shepherd LaSalle UPenn West Virginia
Beginning of trip (yyyy-mm-dd) End of trip (yyyy-mm-dd)
Emergency Contact Name Their Phone Their Relationship to you
Spanish Ability Little or none Some Able function independently
Occupation ADOLESCENT - INTERNAL MED ALLERGY (ADULT) ANESTHESIA ARCHITECT CARDIOLOGY INVASIVE CARDIOLOGY NON INVASIVE CEO1 COMPUTER SCIENCE CONSTRUCTION WORKER CORPORATE LAWYER DENTAL ASSISTANT DENTAL HYGIENIST DENTIST GENERAL DERMATOLOGY DOCTOR NO SPECIALTY YET OR UNKNOWN Not Professor ENDOCRINOLOGY ENGINEER ENT FAMILY PRACTICE Firefighter GASTROENTEROLOGY GERIATRICS GRADUATE SCHOOL PROF GRADUATE SCHOOL PROF MD GRADUATE SCHOOL STUDENT ANY YEAR ANY CAREER HEMATOLOGY/ONC HIGH SCHOOL STUDENT HONDURAN DOCTOR HOUSEWIFE IM GENERAL INFECTIOUS DISEASE LICENSED PRACTICAL NURSE MASSAGE THERAPIST MEDICAL ASSISTANT Medical Student Neonatologist NEPHROLOGY NEUROBIOLOGIST NEUROLOGY NMW NURSE PRACTIONER or midwife OB/GYN GEN OB/GYN GYN ONLY OCCUPATIONAL MED OPTHALMOLOGY MEDICAL OPTHALMOLOGY SURGICAL ORAL SURGEON ORTHO HAND ORTHO SURG SPORTS MED ORTHOPEDIC NON SURG ORTHOPEDIC SURG PEDS ADOLESCENT PHARMACIST PHD PHYSICAL THERAPIST PHYSICIAN ASSISTANT PM & R PODIATRY SURG FOOT/ANKLE PRIVATE PRACTICE ATTORNEY PULMONARY/CRITICAL CARE RADIOLOGY DIAG-NONINV REGISTERED NURSE REGISTERED NURSE WITH MASTERS RESIDENTS ALL YEARS RHEUMATOLOGY SOCIAL WORKER SPORTS MED STAFF OF SHOULDER TO SHOULDER SURGERY GENERAL TEACHER TRANSLATOR UNDERGRAD STUDENT Any Major UNKNOWN UROLOGY
Medical or Dental License Number if applicable
Occupational notes,student year, clarification, etc
Important medical conditions
Dietary Restrictions
Vegetarian
Please be sure you have completed the form with accurate data. You will receive a confirmation email shortly. Thank you for your support of Shoulder to Shoulder.
Please press send to complete the application.
