Volunteer Medical staff
Email address *
I have checked re-entry requirements of my employers before submitting this form. And they are in agreement of me volunteering in Honduras. *
Required
First name ( as spelled in passport) *
Middle initial
Last name (as spelled in passport) *
Date of birth *
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Nationality and Passport ID number *
Passport expiry date *
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Full address *
Phone number *
Place of education *
Employer/ Institution/ Place of work *
What are your credentials? (MD, RN, RT, NP, PA, Paramedic, etc.) Please state in full. *
What will be the earliest date you can be available for travel to Roatan? *
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What would be your necessary date of departure? *
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What is your closest international airport? *
Have you had Covid-19?
Clear selection
Do you have experience with Covid-19 patients? If so, explain your role. *
Do you have any health concerns or limitations that would restrict your role in caring for Covid-19 patients? *
Would you be able to bring your own PPE/ some of your own PPE, as our supplies are limited? *
Are you able to cover the expenses of your travel and food during your trip? *
Please provide the name, relationship, and contact information for your emergency contact. (For US citizens the US Embassy requires that it be a spouse or blood relative.) *
Which languages do you speak *
Required
Please send a short CV, licenses, copy of passport photo page, medical diplomas and /or other relevant documents to : susie@bridge320.org *
Required
A copy of your responses will be emailed to the address you provided.
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