Guerrero Surgery and Education Center

In Guerrero, Chihuahua, Mexico

Spring 2007 Application Checklist

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

Group transportation dates

Pre-clinic setup and clinic

Departs: Tuesday morning April 10^th

Returns Monday morning April 16^th

(Flights depart from, and return to Houston Intercontinental airport)

or

Clinic only

Departs: Wednesday morning April 11^th

Returns Monday morning April 16^th

(Flights depart from, and return to Houston Intercontinental airport)

For Questions Contact: Walter Branson, Director

Guerrero Surgery and Education Center

979-297-1970 work and home

979-236-1970 cell

979-297-6658 fax

Walter@BransonConstruction.com

Guerrero Surgery and Education Center

In Guerrero, Chihuahua, Mexico

Spring 2007 Application

Page 1 of 3

Application must be filled out completely

If you attended last clinic and information is the same just fill in name and information that has changed

Name: (Must be listed as appears on passport or drivers license)

_____________________________ ___________________________ _______________________

(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: ____________________

Skills (Check those that apply)

____ Anesthesia	____ Family Medicine	____ Dentistry	____ Registration
____ Ophthalmology	____ RN	____ Dental Assistant	____ Circulator
____ Optometry	____ Recovery Room	____ Pharmacist	____ Culinary
____ Optician	____ Acuity Tech	____ Bio Medical Eng	____ Transportation
____ OR Scrub (Eye)	____ LVN	____ Director of Patients	____ Construction
____ Auto Refractor Tech
____ Translator (Languages where fluent):
____ Other (PLEASE DESCRIBE)

In Guerrero, Chihuahua, Mexico

Spring 2007 Application

Page 2 of 3

Name: (same as on page 1)

_____________________________ ___________________________ _______________________

(last) (first) (middle)

Dates you want to attend (Check one)

____ Departs: Tuesday morning April 10^th

Returns Monday morning April 16^th

(Flights depart from, and return to Houston Intercontinental airport)

____ Departs: Wednesday night April 11^th

Returns Monday morning April 16^th

(Flights depart from, and return to Houston Intercontinental airport)

Housing (check Cabanas or Family Hospitability)

_____ Cabañas ($20 per night per person)

____________ x _ $20 __ = $____________

Nbr of Nights Per Night Total Cost of Housing at Cabañas

Room mate Preference _______________________ Room Preference _______________

_____Family Hospitability housing (no charge)

Family Preference _______________________________ (if known)

In Guerrero, Chihuahua, Mexico

Spring 2007 Application

Page 3 of 3

Name: (same as on page 1)

_____________________________ ___________________________ _______________________

(last) (first) (middle)

Payment Information

	Unit Cost	Qty	Ext. cost
Volunteer fee, group airfare and group ground transportation (requires traveling with the group) Includes: Round trip air from Houston Hobby Airport to El Paso and ground transportation from El Paso Airport to clinic Southwest Airlines Rapid Rewards # __________________	$600
Volunteer fee, group ground transportation (requires traveling with the group from El Paso) Includes: ground transportation from El Paso Airport to clinic	$350
Volunteer fee only	$250
Cabañas Housing	See pg 2
Shirts ____ Ladies’ or ____ Men’s shirts _____Size	$30
Clinic Hat	$15
Grand Total

For those volunteers providing their own transportation to and from the clinic

I will arrive at clinic on: _____ Tuesday ____ Wednesday

Make Check out to CRYSTAL FOUNDATION % Walter Branson

P.O. Box 1566

Lake Jackson, Texas 77566

or

Credit Card Information

Name as it appears on card_______________________________________

Master Card Number ___________________________________________ Exp Date ________________________

Amount to Charge $______________________________________

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

Signature: ___________________________________ Date: __________________________________