Serving Guerrero Surgery and Education Center

Through the Crystal Foundation

 

Dear Friends of the Guerrero Clinic:

 

It is time to sign up for our medical mission in Guerrero, Chihuahua, Mexico.  Please note that we will have a construction trip in September and a medical clinic in October.  We need volunteers for both so if you or someone you know would fit better in construction,  please ask them to sign up.  If you haven’t been with us before, we promise this will be an experience of a lifetime!  If you’ve been with us before thanks for your decision to be of service to others and give up some of your precious time again.

 

It is important that you review all of the documentation enclosed. 

 

We are growing and experiencing the pains as does any successful operation. We require an application and a deposit in advance to attend the clinic. In some areas we are receiving more offers to attend a clinic than we have space or need.  Therefore we cannot accept everyone who applies.  We will return your deposit if you are not selected for our clinic.  If you are selected to go on the mission trip and you elect to drop out for some reason, we will keep the deposit. 

 

Each volunteer is responsible for paying their own way to participate in the clinic.  The fee is $600.00 and is used to pay air fair, ground transportation, meals, and miscellaneous operational costs.  The member cost does not cover the total cost of producing the medical mission.  We also incur cost for medical equipment and supplies, Mexican support, patient assistance, freight, legal, communication and administration of the clinic.

Most team members stay at Cabanas de la Abuela.  The cost to stay here is $20 per night per person.  Sometimes we have an extra hotel charge in Chihuahua (usually $40 to $50) and can be split with a roommate.  Also, an individual meal cost ($10 range) may be incurred in traveling to or from Guerrero. 

 

Thanks for your desire to help us change lives for the better through the Guerrero Surgery and Education Center.

 

 

 

Walter Branson

Director

Guerrero Surgery and Education Center

 

Application Checklist

 

All Applicants – Including prior team members!

  • Application – Completely filled out, signed and dated
  • Check for $100 deposit  (non-refundable)

        If your application is not accepted, your deposit will be refunded in full

  • Master Card Accepted

 

 

 

 

Physicians, Optometrist, Dentists, and CRNA’s

  • Legible copy of current medical license

·         Short resume/CV—updated yearly

 

 

 

Nurses, NP’s, PA’s, PT’s, and Pharmacists

·         Legible copy of current medical license

 

 

Dates you want to attend (Circle one)

 

·       September 22-26, 2005  (this is a construction trip non-medical) We have to pay a deposit to Continental by August 5th.

 

·       October 10-16, 2005 (this flight leaves at 9pm so you can work at home Monday)

 

·       October 8-16, 2005  this would include the trip to the

Cooper Canyon or the weekend to enjoy Chihuahua

(the Clinic starts on Tuesday).

  

 

 

 

 

 

                       APPLICATION Fall 2005

Guerrero Surgery and Education Center

Application must be filled out completely

 

 

 

Name: (Must be listed as appears on passport)               

       

 

_____________________________   ___________________________   _______________________

        (last)                                                       (first)                                                     (middle)

 

 

_____________________________

                        (nickname)

 

        Home                                                                   Work

 

Address:__________________________________     Company Name:______________________________

 

        __________________________________            Company Address _____________________________

 

        __________________________________                                            _____________________________

 

Phone:    __________________________________    Phone:    _____________________________________

 

Fax:                __________________________________            Fax:        _____________________________________

 

E-Mail            __________________________________            E-Mail__________________________________

 

Cell Phone:________________________________   Beeper:_____________________________________

 

 

Personal Data

 

Passport # _______________________ Date Issued: __________ Place Issued______________ Exp. Date________

 

Birth Date _______________     Citizenship (country)_______________________ Spouse: ____________________

 

Housing:   Cabanas ____________ ($20 per night per person) _______________________Room mate Preference

          

           Family Hospitability housing ____________ (no charge)  Family Preference  ___________________

                                                                                                               (if known)

 

         

 

 

 

 

Skills (Circle those that apply)

 

·          Anesthesia                                                                    ·    Auto Refractor Tech                         

·          Dentistry                                                                       •      Acuity Tech                                        

                ·          Ophthalmology                                                            •       Registration

·          Family Medicine                                                          ·          Director of Patients

·          Optometry                                                                     ·          Construction

·          Optician                                                                        ·          Other ______

·          OR Scrub (Eye)

·          Circulator

·          RN

·          LVN

·          Recovery Room

·          Pharmacist

·          Dental Assistant

·          Bio Medical Eng.

·          Translator

·          Transportation

·          Culinar

 

 

 

 

 

Languages you are fluent in.    ________________    

 

 

 

 

Credit Card Information

       

        Name as it appears on card_______________________________________

 

        Master Card Number ___________________________________________

 

        Expiration Date ________________________________________________

 

        Amount to Charge $_____________________________________________

 

 

I have carefully reviewed & completed all information in this application form.

 

Signature: ___________________________________

 

Date: _______________________________________