Membership Print

Medical Wings International Membership Application

***Membership runs one year from month joining

Date: ____/____/____

Tell us how we may contact you:

Name:	__________________________
Address:	__________________________
City/State/Zip:	__________________________
Telephone:	__________________________
Cell Phone:	__________________________
Fax:	__________________________
E-mail:	__________________________
Marital Status:	__________________________

Contact/Emergency:
Name:	__________________________
Telephone:	__________________________

Membership Donation:
Annually ( Tax Deductible)

__ $35 Student Only	__ $50	__ $100
__ $150	__ $200	__ $250
	__ $500

I would also like to donate:

___ My Time ___ Supplies

___ Over the Counter Medicines

Payment Information:
__ Personal Check
__ Money Order

Healthcare Specialty: ___ Physician ___ Nurse ___ Dentist Other: ____

Please include a copy of your medical license with the application (medical professional only)

Please make checks payable to Medical Wings International.
Print the application and mail both check and application to:

Medical Wings International
P.O. Box 610542 Dallas, Texas 75261
Phone 817 375 8111
Fax 817 375 8144
Email - info@medicalwings.org

Unlimited Opportunities along the way. You will meet terrific people who share a common bond to help others. And as you work together for a greater good, you will build camaraderie as you test your skills and endurance.