Global Medicine Network Registration (Individual)

Individual Member Registration

Thank you for registering with the Global Medicine Network! Joining the Global Medicine Network is easy. The form below should take no more than 5 or 10 minutes to complete.

In the first section, you will enter basic contact and skills information. In the second section, you will be asked to briefly indicate your particular areas of interest in global health. This will create your profile which you and others in the network can use to match up common skills and interests. And lastly, you will create a user name and password to log into the network as a registered member.

We thank you for your interest in the Global Medicine Network

—The Massachusetts Medical Society Global Medicine Committee

Section 1: Contact Information and Skills

Required information is in red.

If you would prefer the GMN to publish only your Last Name, First Name, and Email address to the GMN site, please check this box:

Last Name
First Name
Email
Street/Postal Address
City/Town
State/Province
Zip/Postal Code
Country
Phone
Fax

I am a member of the Massachusetts Medical Society.

I am a member of the MMS Alliance.

Please choose your areas of expertise from the lists below (hold Control or Command Key and click to select multiple items).

Doctor:
Nurse:
Oral/Dental:
Medical Support:
Other Medical Field:
Researcher:
Student:

Please indicate which languages you speak. Choose as many as are applicable. (Hold Control or Command key and click to select multiple items.)

Language

If you like, please enter a brief description of yourself here (3000 characters limit):

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Section 2: Interests

There are many ways to participate in the Network, based on your interests.� Please check all the items that interest you.

Professional Service and Visitor Exchange

	I would like to volunteer for work in another country
	I am interested in paid work in another country
	I can help find/update service opportunities for colleagues in other countries
	I can help find/update service opportunities for colleagues in my own country
	I would like to help find/update international service opportunities for students/residents
	I am interested in joining an international disaster/crisis response team.
	I would be willing to provide Email consultations to colleagues.
	I can help arrange international exchange opportunities.
	I can host a colleague, resident or student in my home/office/school/hospital.

Education

I am available to lecture/teach in another country.
I would like to design/deliver/coordinate training programs.
I would like to write/review educational material.
I can translate health material into these languages:

Language:

I can contribute to Newsletter/Listserv Emailings on global health.
I would like to participate in educational meetings.

Research

Please enter a brief description of your area(s) of research interest/expertise below (3000 character limit):

	I would like to collaborate on international health research project(s).
	I can provide overseas opportunities or contacts for research related to international health.
	I can suggest or coordinate research activities related to international health.
	I would like to participate in meetings regarding international health research.

Advocacy

	I can promote awareness of international health issues.
	I would like to assist in international health advocacy campaign fundraising.
	I can contribute financially to an international health advocacy campaign.

Supplies and Equipment

I can donate
medical supplies or equipment.
medical books or journals.

I would like to receive
medical supplies or equipment.
receive medical books or journals.

	I can identify sources of medical books, journals, supplies or equipment.
	I can collect and share information about shipping/transportation.
	I can collect and share information about potential pharmaceutical donors.

Organizational Assistance

	I can promote contacts among individuals and organizations in my area/country.
	I can promote contacts among individuals and organizations in other countries.
	I can recruit additional members to join the Network.
	I would like to participate in a GMN organizational committee.
	I can write/review grant proposals to fund international health projects, including the Global Medicine Network.
	I can identify funding sources or contribute financially to the GMN.

Please indicate any countries in which you have personal contacts. Choose as many as are applicable (hold Control or Command key and click to select multiple items):

You have almost completed the registration process!

Is there anything you would like to add about yourself?
(Limit 3000 characters):

All that remains to do now is to choose a username and password. Save them so that you can update or delete your record from the registry at a later date. (Required information is in red.)

Username Same as your Email

Password

Confirm Password

Press the "submit" button below after reviewing your answers.

Thank you!

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