Now that you have been accepted into the program, we need to collect a little more information about you. Please take the time to fill this out, as it contains a lot of important data!

Name *
Name
Your Current Address *
Your Current Address
Emergency Contacts
We require two contacts. One should be your parent or legal guardian. We suggest the phone number you provide is a mobile device where your contact can be reached at anytime.
Preferred Contact *
Preferred Contact
Preferred Contact's Phone Number *
Preferred Contact's Phone Number
Preferred Contact's Home Address *
Preferred Contact's Home Address
Secondary Contact *
Secondary Contact
Secondary Contact's Phone Number *
Secondary Contact's Phone Number
Secondary Contact's Home Address *
Secondary Contact's Home Address
More About You
Please take the time to answer these questions honestly. They are quite important, and they will help us make sure you have the most enjoyable experience!
If not, leave blank!
If not, leave blank!
If not, leave blank! We will not share this information with anyone except our team.
Be as general or specific as you wish, we aren't a med. school admissions board...
If you thought you already answered this with the last question, think again!
We already know you're interested, or you wouldn't be on this trip, but are there any areas that you are passionate about? E.g.: woman's health, infant care, economic factors...
This doesn't have to be confined to the developing world; disparities in healthcare exist in the "developed" world as well.
There's no wrong answer here...kind of.
...in a world where you actually have time outside of school work and extracurricular activities.
E.g.: A dolphin, because they have a lot of fun...and are very smart.
E.g.: Michelle Williams, because she can handle anything.
You can't ride an elephant, or go skydiving. Sorry we're not sorry.
Within reason, please list any requests, questions, or concerns in the area provided below - if you write nothing, we will just assume we are awesome.