MM Participation Form

Please Note: There is a USD$200.00 Participation fee. After your acceptance for the Mission, we will contact you and advise you where/when to send your check. We do not accept Credit Cards.

The Rotary Club of South Platte, The Philippine Medical Society of Greater Kansas City, & The Philippine Nurses Association of Greater Kansas City, All hold 501 c3 tax status.

Here is the Form to fill out if you are interested in going on the next Medical Mission.

The fields marked with (*) are required fields.

*

First Name

* required

*

Last Name

* required

*

Address Line 1

* required

Address Line 2

*

City

* required

*

State

* required

*

Zip Postal Code

* required

*

Country

*

Telephone Number

* required

*

Email Address

* required

*

Place your Medical Speciality and Team desired here..

Please Note: There is a USD$200.00 per person participation fee for each Medical Mission Member. After your participation acceptance, you will be advised of the "Where-When" to send the $200.00. This is to HELP defray the costs for Hotels/meals/bus/tips. etc..etc it does not cover your total cost. To participate in this mission we desire if at all possible, your involvement with the supplies packing, and most importantly, help with the fund raising golf tournament. Please add any comments or questions to the box on the right.