GUADALAJARA VEINS NON PHYSICIAN

ENCUESTA PREVIA A LA BRIGADA DE PROLOTERAPIA

Nombre de pila

Apellido

Date of Birth

Address Please include: City | State | ZIP | Country

Correo electrónico

Telefono de oficina

Cell phone

Do you have access to WhatsApp?

What is your job/career? If retired, what did you do?

Will you be traveling and participating in this service learning trip with any friends or family? Please note, the minimum age to volunteer is 14 years old.

Yes

GENERAL EXPERIENCE

How did you hear about us?

Are you a new or returning participant?*

Novice - this will be my first trip

I have been once before

I have been two or more times

¿Cuál es UN área que le gustaría aprender/mejorar durante esta brigada?

Please describe any relevant training or experience you have. If none, please state none.*

Do you speak Spanish?

I am proficient in medical spanish

I am fluent in spanish

Please note, once your application is reviewed and approved, you will receive a second part to this application process.

¡Gracias por enviar!

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