Medical Mission Partnership Application

If you have questions, please contact Jamie Cali at jcali@globusmedical.com

"*" indicates required fields

Your Name*

Email*

Phone*

Phone format: (###)###-####

Country of Residence*

Are you connected with a nonprofit?*

If yes, please upload the IRS Tax Determination Letter

Max. file size: 50 MB.

Medical Mission Location (country, city)*

Mission Start Date*

Mission End Date*

Surgeon Name(s)*

Mission Hospital Name*

Mission Hospital Address*

Local Hospital or Surgeon Partner Contact:*

Support Needed:*

Spinal Hardware (Instruments + Implants)

Neuromonitoring

Funding (Travel, Customs & Shipping, Patient Care)

Trip Operations and Administrative Support

Volunteer Recruitment

Please select all that apply.

If you are requesting spinal hardware, please upload a list of items

Max. file size: 50 MB.

If requesting funding, how much? USD Amount

If requesting funding, please upload a budget and/or use of funds breakdown

Max. file size: 50 MB.

Please summarize the objective of your medical mission*

Who will make up your medical mission team? Please list name, role and email*

Have you traveled to this site previously? If yes, how many times?*

Is this a recurring trip? If yes, do you have other dates set?*

How many surgeries are you planning?*

Please give your best estimate

What type of surgeries are you planning?*

Please give your best estimate

Will you provide training to local medical professionals during your trip?*

Are you requesting support from other organizations?*

If yes, please explain

Anything else we should know?

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