SEMILLA Volunteer Application

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Name *

Email Address *

Cell phone number *

What is your current status? *

Academic Faculty

Community Attending

Mid-Level Provider (NP/PA)

Nurse

Fellow

Resident

EMT

Medical Student

Pre-Med

Other:

If you have a current university affiliation, please name

What is your level of ability in Spanish?

Native

Fluent Non-native

Proficient

Conversant

Minimal

None

Clear selection

If you have significant prior experience in Global Health Projects please describe

Of the following committees, please indicate your top three choices on which you would like to volunteer: *

please check your top 3 choices

Resuscitation (Cardiac arrest, trauma, difficult airway, pediatric resuscitation, simulation)

Pre-hospital care (first aid, EMS development)

Ultrasound

Equipment/donations/corporate sponsorship

Grants/research/publications

Membership/media/social media/branding/newsletter

Emergency Medicine Specialty Development

Required

Do you have any particular skills that are relevant to Project SEMILLA that we should know about? (Examples: grant writing, accounting, web development, photography, statistics, translation, editing). Please describe

Do you have particular interest/contacts for the development of Emergency Medicine in a country other than Nicaragua?

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