Medical Mission Partnership Application | NuVasive Spine Foundation

If you have questions, please contact Jamie Cali at [email protected]

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: 100 MB.
Medical Mission Location (country, city)*
Mission Start Date*
Month
Day
Year
Mission End Date*
Month
Day
Year
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: 100 MB.
If requesting funding, how much? USD Amount
If requesting funding, please upload a budget and/or use of funds breakdown
Max. file size: 100 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?