Mission: 2026-06 Clay Medical

A mobile medical team led by Dr. Angela Clay that will be serving in San Juan de la Maguana. Before completing this form, please download and review our Consent Form (PDF).

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First Name

Last Name

Email address

Personal Information

Previous Experience:

Occupation:

Marital Status

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Gender

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Emergency Medical Information

Emergency Contact:

Relation:

Phone Number:

Alternate Phone Number

Allergies (Medications, Food, etc.):

Medications Being Take:

Date of last Tetanus Shot:

Chronic Medical Conditions:

Other Relevant Information:

Physicians Name:

City:

State:

Physicians Phone:

Health Insurance Company:

Policy Number:

Church Affiliation (Optional):

Church Name

City

State

Waiver

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Volunteer Signature:

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Guardian Signature:

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Date:

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Mission: 2026-06 Clay Medical

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