1000 Smiles (Jamaica/St. Lucia/Grenada) & Sealant Project Application/Intake Form 2018
First Name (Your LEGAL FIRST NAME) *
Your answer
Name you prefer to be called on nametag *
Your answer
Last Name *
Your answer
Your Profession
I am a:
Please select the one week that would be your first choice to volunteer: *
In the box below, please list alternate weeks that you are available and willing to go if your first choice is not available *
Your answer
The majority of our volunteer spaces are one week spaces, however we do have very limited two week spaces that are granted based on availability, volunteer seniority, clinic need, etc. If you’d like to apply for a 2 week space please let us know which session below.
Alternate dates
If you wish to volunteer for any dates outside of the above offered please email us: josephgreatshape@gmail.com and copy shantellegreatshape@gmail.com and tiffanygsjamaica@gmail.com
Your answer
Email Address *
Please note, if you are filling out an application for multiple people, PLEASE provide a unique email address for each application. We CAN NOT send multiple DocuSign packets (volunteer paperwork) to the same (one) email address.
Your answer
Please provide an alternate email address in case of technical difficulties: *
Occassionally, we have technical challenges with DocuSign (especially with university emails) so it's helpful to have a 2nd email on file if you have one. If you don't have an alternate email please write N/a below.
Your answer
Best Phone Number Type *
Work Phone Number *
Your answer
Cell Phone Number *
Your answer
Home Phone Number *
Your answer
What are the best days to reach you (please note if there are days that your office is closed) *
Your answer
The best mailing address to reach me is my: *
Work Address - Street *
(include apt or suite #)
Your answer
City *
Your answer
State/Province *
Your answer
Zipcode/Postal Code *
Your answer
Country *
Your answer
Home Address - Street *
(include apt or suite #)
Your answer
City *
Your answer
State/Province *
Your answer
Zipcode/Postal Code *
Your answer
Country *
Your answer
Select which statement applies to your volunteer experience with Great Shape! Inc. *
Gender *
Birthdate *
MM
/
DD
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YYYY
Including this year, how many years have you volunteered on this project? *
Ex: If this is your first year volunteering you would select 1, if this is your second year volunteering 2
T-Shirt Size *
Travel Documents *
Every visitor to Jamaica/St. Lucia is required to have a valid passport that does not expire during your dates of travel. All volunteers must submit their passport number and expiration date with their Ministry of Health paperwork. If you have any questions about travel documents please contact shantellegreatshape@gmail.com. Please bubble the following now:
Please tell us about your travel docs here: *
List the country that your passport was/will be issued in: *
Your answer
Passport # *
If you are waiting on your passport # you can put "PENDING" in the box below. Email your passport number to shantellegreatshape@gmail.com & copy tiffanygsjamaica@gmail.com once you've received it.
Your answer
If this is your first year, how did you find out about us:
Please provide us with the name of the volunteer(s) or group if you were referred to us
Your answer
If you are a returning volunteer would you be willing to speak with a first time volunteer of your same profession about what to expect? If so, we will connect you by email and you can make arrangements to speak by phone if needed.
Emergency Contact Information *
Name, Phone Number, Relationship
Your answer
Serious Medical Conditions/Medications, Allergies we should be aware of in Case of Emergency *
You can write N/a if there are none
Your answer
Roommate Preferences
There are 3 persons to a room on our project, except for couples who can pay extra to secure a private room on a space available basis. We do our best to place each volunteer in their desired clinic location, in their desired job (role), with their desired roommates and with their desired team members. However, we ask everyone to be flexible in the spirit of the project. By participating, you are accepting the possibility that we may not be able to meet all your preferences in the above.
Do you have 1 or 2 other roommates confirmed yet?
This means that you have talked to them and you all agree on the same thing.
If yes, what are their names:
Your answer
Would you like to have a private room, if available?
If you would prefer to have your privacy, if space allows and is approved, you can pay a 3rd project fee to guarantee a room for two.
If no, then what is your general bed time:
Other Roommate Concerns?
Your answer
Teammate Preferences:
Please tell us who you prefer to work with or any other teammate concerns:
Your answer
Clinic Preferences:
Great Shape! operates 3 to 4 clinics in rural community settings within 1 hour of our host hotel. In addition, we operate a staff clinic at each Sandals hotel with 1 or 2 chairs. Please indicate by checking your preference/willingness to work at the Sandals staff clinic as noted below:
Please note any other location preferences here:
Your answer
If Dentist:
We ask all our volunteers to be flexible with work assignments and often our dentists find themselves outside of their regular "comfort zones" in terms of age groups served, procedures performed and/or equipment available to do the work. The following questions are designed to help us best place you on the project. First please select what type of dentist you are:
Procedures: How willing/comfortable are you in doing restorations and extractions.
Comments:
For example, if you are a dentist that specializes in oral surgery or if you are a dentist that prefers working with children let us know that here.
Your answer
Current dental license #
Your answer
State that your current dental license is registered under:
Your answer
If Hygienist:
Please tell us what kind of hygienist or any other information about your specialty or experience that you may have that will help us understand how to best place you on our teams. For example, if you are a hygienist that specializes in restorative work or loves placing sealants on children's teeth, please let us know that.
Your answer
If Hygienist, are you licensed and comfortable doing restorative?
Anesthetic?
Do you have a Cavitron to bring with you?
Current dental hygiene license #
Your answer
State that your current dental hygiene license is registered under:
Your answer
If you are a recent graduate dentist or hygienist, but do not have your license yet let us know here.
Let us know when you expect to receive your license.
Your answer
If a Dental/Hygiene Student, what is the name of your dental school?
Your answer
Dental Students: What year are you at the present moment?
List the procedures that you have performed in clinic prior to your participation in the program:
Ex: Cleanings, simple fillings, complex fillings, simple extractions, and surgical extractions
Your answer
If Dental Assistant by profession...are you trained to do sealants?
Do you have any other expanded functions? If so, please tell us below:
Your answer
If you selected “Other”, please tell us what your profession is and what experience, if any, you have had in the dental field, international travel or humanitarian work.
Your answer
If non dental professional...we ask all of our non dental professionals to be flexible with their support role. You may even be asked to change jobs in the middle of the project. Please rank the roles below in order of preference:
Sterilization: works in the clinic sterilizing instruments and general clinic support. Dental Assistant: Provides chair side assistance to dentist, comforts patients. Patient Registration: Manages the patient list and getting patients into empty chairs. Education team: Visits schools to teach oral hygiene and distribute brushes and paste. X-ray Radiography Assistant: Operates the imaging software used to view x-rays. Captures x-ray images on a digital x-ray system with the assistance of a dental professional.
First Choice:
Second Choice:
Third Choice:
Fourth Choice:
Fifth Choice:
Other Requests or Concerns:
Your answer
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