Operation: Seabird Medical Personnel Form

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Fill out the following information to be added to our medical roster for Typhoon Haiyan relief

First Name *

Last Name *

Phone Number *

Email *

Valid Medical Licenses *

Mark all that apply

Advanced Tactical Practitioner (ATP) - 18D, PJ, Ranger Medic, Navy IDC

CPR/First Aid

Certified Dental Assistant (CDA)

Certified Emergency Flight Nurse (CFRN)

Certified Emergency Nurse (CEN)

Certified Respiratory Therapist (CRT)

Clinical Nurse Specialist (CNS)

Critical Care Nurse Specialist (CCNS)

Critical Care Registered Nurse (CCRN)

Doctor of Chiropractic (DC)

Doctor of Dentistry (DD)

Doctor of Medicine (MD)

Doctor of Nursing (ND)

Doctor of Osteopathy (DO)

Doctor of Pharmacy (PD)

Emergency Medical Technician - Basic (EMT- B)

Emergency Medical Technician - Intermediate (EMT- I)

Emergency Medical Technician - Paramedic (EMT- P)

First Responder

Hospital Technician

Licensed Vocational Nurse (LVN)

Medical Student I

Medical Student II

Medical Student III

Required

Provide additional information about medical experience and licenses *

e.g. OB-GYN, Trauma Surgeon, etc.

Start Date *

Date you can deploy to Philippines

End Date *

Date you can deploy to Philippines

YYYY

Valid Passport? *

Cannot expire within six months of deployment

Yes

Fluency in Filipino Languages *

Tagalog

Cebuano

Ilokano

Hiligaynon

Waray-Waray

N/A

Other:

Military Experience? *

Yes

Provide additional information about military experience *

Overseas Medical Experience? *

Yes

Provide additional information about overseas medical experience *

Submit

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