MEMBERSHIP APPLICATION

Instructions for this application:
Complete the information below then print this form and submit with payment to:
DOCARE, 142 E. Ontario, 4th Fl. Chicago, IL 60611

Membership in DOCARE International is open to healthcare professionals of all persuasions, including students and lay people with special skills.

As an all-volunteer organization, members have the option of participating in DOCARE's medical outreach missions or, as many do, join to help support its humanitarian programs.

DOCARE is non-profit and tax-exempt, so membership dues, donations, gifts, and grants are all tax-deductible. Those interested in joining the DOCARE team can print the membership application below and send it, along with a dues check for the appropriate category of membership to the address at the bottom of of the page.

Name:

Degree(s):

Address 1:

Address 2:

City: State: Zip:

Phone: Fax

Email Address:

Country of Citizenship:

Occupation:

If you are a physician, what is your specialty?

State(s) of Licensure (if applicable):

Students Only- Osteopathic Medical School and Graduation Date:

Which foreign language(s), if any, do you speak?

Would you like to participate
in future DOCARE Missions?

Yes

Maybe

Please select your membership category from the choices below:

Regular	$50 per year
Student	$30 for duration of medical school
Intern/Resident	$50 for duration of residency
Family includes non-medical spouse and dependent children	$60 per year
Life (must be 60 or over)	$500 one-time payment

PAYMENT INFORMATION:

Visa

Mastercard

Name on Card:

Expiration Date:

Check No.

Once you have completed this form, PRINT and submit with payment to:
DOCARE, 142 E. Ontario, 4th Fl. Chicago, IL 60611