MILU-EM intake form
Join our EM volunteer team supporting EM needs in Israel now and moving forward
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Email *
Name (Last, First) *
Email address *
WhatsApp number (+international country code, followed by phone number) *
Country code eg. +1, +972
Phone number (if different from WhatsApp)
Have you previously completed any of the following Israel medical volunteer application intake forms?
In what country are you currently licensed to practice medicine? *
Required
Are you board certified in Emergency Medicine?
How many years have you been working in EM post-residency? *
Current workplace / hospital system *
Name of workplace(s) where you practice EM
How would you describe you current clinical practice environment (please check all that apply) *
Required
University affiliation(s) and faculty appointment
University name, faculty appointment
Current or past EM leadership experience
Emergency Medicine Subspecialty Training *
Required
Select the statement that best describes your Hebrew language skills *
Other language skills *
If none, list ‘none’
Prior Israeli Medical work experience (brief description and duration) *
If none, list ‘none’
How early can you likely be available to go to Israel for a 2 week trip? *
Required
What would be your regional or city or hospital preference(s) for placement? *
If you don’t have any preference, list ‘any’
How much support do you have from your ED chief and/or department to participate in medical relief efforts in Israel over the coming months/years? *
Lots of support
Poorly supported
How likely are you to be able to return to work in Israel on a voluntary basis in the coming 3 months after your initial visit (assuming all travel costs are paid for)? *
Very likely to come back within 3 months
Unlikely to come back within 3 months
How likely are you to be able to return to Israel to provide education and clinical support every 3-4 months over the coming 2 years once this current war is over (assuming all travel costs are paid for)? *
Very likely to come back every 3-4 months over the next 2 years
Unlikely to come more than once over the next 2 years
Any questions? We will do our best to respond in a timely manner.
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