Hand Help Team Member Registration
Please use this form to submit your information and supporting documents. This helps us obtain medical clearance in the host country.
Email address *
Name (as shown on your passport) *
Date of Birth *
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Professional Title *
Degree/Licensure (e.g. MD, RN, CRNA, CHT) *
Mailing Address *
Home Phone *
Mobile Phone *
Emergency Contact Name *
Emergency Contact Relationship *
Emergency Contact Phone *
Photo (Headshot) *
Please upload an image file that shows your face.
Required
Curriculum Vitae *
Please upload your CV as a PDF file.
Required
Passport Number *
Passport Country *
Passport Expiration Date *
MM
/
DD
/
YYYY
Passport Cover *
Please upload a scanned image of the front and back covers of your passport.
Required
Passport Photo Page *
Please upload a scanned image of the inside pages of your passport containing your identifying information and photo.
Required
Professional Degree Diploma *
Please upload a scanned image of your degree or licensure diploma. E.g. M.D., nursing, therapy, etc.
Required
Current Professional License *
Pleaes upload a scanned image of your current professional license.
Required
T-shirt Size *
Surgical Glove Size *
Hotel Room Preference *
Additional Comments
A copy of your responses will be emailed to the address you provided.
Please complete the captcha before submitting the form.
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