Application for Medical Volunteers
Email address *
First Name *
Your answer
Last Name *
Your answer
Cell *
Your answer
Zip
Your answer
Do you have a valid US passport OR an original birth certificate with a raised seal and a drivers license? *
Are you over the age of 18? *
What is your area of specialty?
Do you have an M.D., D.O. or Pharm. D. and a current valid license?
Are you a nurse? If so, what is your area of expertise? *
Your answer
Are you a P.A.? If so, what is your specialty? *
Your answer
Are you a Nurse Practitioner? If so, what is your specialty? *
Your answer
Do you have another type of medical training not described here? If so, please explain. *
Your answer
Do you have any relevant experience in disaster relief? If yes, explain.
Your answer
Do you have two years relevant experience in post-residency?
Have you had at least six months of clinical practice within the last two years?
Do you have any professional experience supervising, training, or managing staff?
List the languages in which you are fluent
Your answer
Do you have graduate studies in any of the following
Please check the days of the week you are available *
Required
Are you available from Friday September 13 to Monday September 16? *
Would you like to be notified of upcoming medical missions? *
Do you have any other relevant experience not described here?
Your answer
Did you volunteer on the first Bahamas Relief Cruise? *
A copy of your responses will be emailed to the address you provided.
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