Shree Bidada Sarvodaya Trust

Non-Profit Charitable Organization
Bidada Hospital, Village: Bidada, Taluka: Mandvi-Kutch. Gujarat-INDIA. 370435.
Tel. (02834) 244 444/244 143. Fax: (02834) 244 466. Email: bidadahospital@hotmail.com - Website: http://www.bidada.org
USA: 11403 Tortuga St., Cypress, CA, USA 90630.
Tel. (714) 898 3156. Fax: (714) 893 0055. Email: manilalmehta@msn.com

Medical Camp Registration Form
If you are a physician or volunteer who would like to attend the camp please provide the following information:
Title First Name Last Name Sex/Age Speciality Departure Date Return Date Email Address US Phone/Address India Phone/Address
                   
Note: If departure or return is city other than Mumbai, please specify:
Choose One:  Resident/Medical Student Year: 
If Physician/Resident/Medical Student/Nurse:
Medical Degree:
Country/State/Year Degree Issued:
Professional Affiliation:

 If Volunteer:
Education:
Areas of Interest to Volunteer:
Additional comments or information:
MAIL OR FAX FORM TO
(If Physician or Resident please also send your CVC and State Registration)
Dr. Manibhai Mehta
11403, Tortuga Street, Cypress CA 90630
Telephone: 714-898-3156
Email: manilalmehta@msn.com		 Camp Site: Bidada Hospital, Village Bidada, Kutch,
Gujarat India
Contact Vijay Chheda Trustee
Telephone: 714-654-6097
Email: vijaychheda@hotmail.com		 Contact in Mumbai
Maru Hospital: 2471 7272/2471 7474
Vijay Chheda: 2614 0999
Purvi Cell: 98208 12202