CURRENT HEALTHCARE PROFESSIONAL REGISTRATION FORM 2020
Thank you for taking an interest and applying to work with Team Kitrinos Medical Services.

We are currently working in various locations, but currently mainly in Camp Moria, Lesvos. By completing this form you are not committed at this stage to work with us, so please do not book any flights yet. We will need to get authorisation for you to enter the camps and all the requested paperwork will need be submitted before your planned date of arrival.

Please complete all sections fully. The questions marked with * are compulsory
Full name *
Please complete as it appears in your passport or ID document ?
Date of Birth *
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Address 1 *
House/ flat no and street
Address 2 *
Post code/ Country
Telephone *
[Include full international dialing code]
Is this number on 'Whatsapp'? If not please add an alternative phone number below?
[Whatsapp is the main method of communication on the ground and its useful to have a phone compatible with this]
E-mail *
Skype name
(if you have one)
Next of kin *
Name, relationship and contact details ( phone & e-mail)
Skills and Qualifications
What type of healthcare professional are you? *
Choose the most senior qualification
If you are medical doctor please choose type:
(Medical doctors only- you may skip this question if you are not a doctor)
Do you have a prescribing licence?
Clear selection
If you are a prescriber, what is your registration number?
Date of Primary Qualification *
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Date of last CPR update
[Don't worry if this is out of date as we can try to arrange an update]
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Relevant experience or skills?
We may ask you to assist with non-medical tasks during your stay. Please select all from list below that apply:
Have you got suitable medical indemnity (legal defence) cover as humanitarian health worker? *
All doctors are advised to inform their medical indemnity provider about the type work they intend on doing. At present this is through a mobile medical unit in Northern Greece.
Have you got travel health insurance? *
This is strongly recommended. Please provider name and number (or if within EU your E111 card number). It is upto each volunteer to ensure that they are adequately covered.
Do you have the following certificates?
Please scan all certificates from the following list to a folder on googledrive and email to volunteer@kitrinoshealthcare.com
Are you medically fit and well? *
If No, please specify in the notes at the end.You should consider any personal health issues from an early stage because having a current or previous significant medical history may limit your volunteering options.
Are you taking any medication? *
If Yes, please specify in notes at the end
Do you wish to declare a disability *
If you answer Yes- please provide more details in the notes section at the end. Some of the environments we work in are challenging. It may be difficult for us to match your professional and personal circumstances with a volunteer role. We'll make every effort to consider all possibilities and think flexibly to enable the volunteering experience.
Do you have specific dates on which you are available?
You will be allocated slots based on our needs to fill in gaps and we will do our best to accomodate your preference although a degree of flexibility would be appreciated.
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What duration can you be available for?
[In terms of orientation, training and prioritisation for any available volunteer accomodation, those with longer periods of stay will be prioritised]
Please indicate if you have been vaccinated against: *
Please tick all that apply. Please scan a copy of Hepatitis B immunisation serology report and send with other certificates.
Required
Please enter dates for all vaccinations above *
(You may complete later once information has been obtained by revisiting this link and using the edit facility)
Please write in your own words why you would like to volunteer with our team?
Due to the destruction of our clinic and equipment in the Moria fires, we are urgently in need of extra funding. Would you be happy for us to set up a fundraiser on your behalf on TotalGiving? NOTE: you will be able to amend the fundraising page once complete.
Clear selection
Notes
Please use this section to add additional notes about any of the above questions.
As a volunteer from the healthcare profession, *
Required
How did you heard about us?
Clear selection
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