Missions Form Register for a Mission! VOOM Foundation Medical Staff Info Form "*" indicates required fields Step 1 of 3 33% FacebookThis field is for validation purposes and should be left unchanged.Contact Info Individual Business Business/Organization Name*Name* Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Prefix First Middle Last Suffix Email* PhonePhone Type Work Mobile Home Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Additional Information for Your OrderSelect Mission Dates Requested* April 29-May 10, 2026 - Pediatric Open-Heart Surgery Team & Interventional Cardiology May 7-18, 2026 - Pediatric Aftercare May 8-17, 2026 - Adult Open-Heart Surgery & Interventional Cardiology July 3-16, 2026 - Adult Open-Heart Surgery (Aftercare - July 11-16, 2026) September 30-October 12, 2026 - Pediatric Open-Heart Surgery Week 1 & Interventional Cardiology October 7-19, 2026 - Pediatric Open-Heart Surgery Week 2 Through October 26, 2026 - Pediatric Aftercare October 16-25, 2026 - Adult Open-Heart Surgery & Interventional Cardiology Through October 29, 2026 - Adult Aftercare December 4-13, 2026 - Adult Open-Heart Surgery Please list your medical profession - be specific please. (Ex. If you are a nurse, please state type such as OR Nurse, ICU Nurse Scrub Technician and please state if you are a cardiac trained ex. CTICU nurse, CTOR Nurse.....etc....) (If you are not a medical professional please list your desired mission role - ex. Admin, general, etc.)*Do you treat adult/pediatric/both?* Adult Pediatric Both Non Medical Volunteer What is the full name of the hospital/organization that you work for?*How many years of cardiac experience?*Are you licensed or certified?*Please provide your license #*License number (N/A if not applicable):*List the name of the place you received licensing or certification.*What is your birthdate?* MM slash DD slash YYYY What airport will you depart from?*Please type your name exactly how it appears on your passport that you are entering Nigeria with:*What is your passport number that you are entering Nigeria with? A copy of your non-expired passport will be due to the VOOM office 60 days before departure in order to process your entry VISA.*Date of Passport Expiration* MM slash DD slash YYYY Are you Covid & Yellow-fever vaccinated?*SelectCovidYellow-FeverBothPlease select a United States Unisex Scrub Size. (If available, VOOM will provide one set of scrubs). The hospital does not have scrubs available for medical staff use. Please bring several sets with you.*SelectX-SmallSmallMediumLargeX-LargeXX-LargePlease list any special dietary needsCost Requirement - VOOM Foundation asks each medical staff member to cover the cost of the following: (International Airline Ticket) (Entry VISA into Nigeria) Although we request you pay for your airline ticket and VISA, you have the option to raise the funds for your trip. *** Funds raised will go toward your base coach airline ticket and VISA entry. Passports, airline upgrades and cost of vaccinations are the responsibility of the volunteer. ANYONE who will need help with financial assistance needs to contact Jenna, admin@voomfoundation.org, as soon as possible. VOOM Foundation does not provide spending money, service tips, extra luggage and leisure activity costs. (Meals and lodging will be provided by VOOM Foundation).*SelectYes, I Confirm AboveIf you are on pediatric medical team and receiving free Emirates flights, you are required to pay for your VISA upfront.*SelectYes, I Confirm AboveWould you like to set up a fundraising page to cover your costs of the trip? Funds raised will cover basic economy airline ticket and entry VISA cost. Fundraising campaigns do not support payment of passports, airline upgrades or vaccinations. Any additional funds raised will help support patient scholarships and missions costs.*SelectYesNoEnter fundraising amount to cover expenses - ($3500 covers the cost of travel and visa, additional funds raised will be used toward patient care)If you are fundraising to support your medical mission costs please write a few sentences or short paragraph as to why you are serving and what you look forward to most about joining this mission.How were you referred to VOOM Foundation? (please provide specific names)*Please upload your most recent CV/Resume. You are required to submit before departure for the mission.Max. file size: 1 GB. Please upload the passport you are ENTERING Nigeria with (must be valid within 6 months of your return date of travel)Max. file size: 1 GB. How were you referred to VOOM Foundation? (please provide specific names)*Gender*SelectMaleFemale Medical Volunteer : Volunteer Terms & Privacy * "Agree to Mission Staff Policy & Procedures Manual” Yes, I agree to VOOM Foundation policies and procedures.
