Volunteer Application

Transcription

1 Volunteer Application Application Instructions This application must be completed using Adobe Reader 1. Save a blank application to your desktop 2. Download and install Adobe Reader: 3. Complete the following sections a. Every applicant completes sections 1-4 b. Oregon or Washington Office applicants complete section 4A c. International Team applicants complete section 4B d. Mobile Dental applicants complete section 4c 4. Save a completed application for your records 5. Send completed application to: volunteer@medicalteams.org 6. You will receive next steps in the mail in 7-10 business days Portland, Oregon Headquarters Western Washington Office PO Box rd Ave NE Portland, OR Redmond, WA Phone Fax Phone Fax Updated July 2013

2 SECTION 1: GENERAL INFORMATION ATTENTION TO: Date: / / First, Middle and Last Name: _Name you prefer: Home Address: City: State/Province: Postal Code: Country: Home Phone: Mobile Phone: Work Phone: Preferred Method of Contact: Home Mobile Work Birth date: / / Spouse Name: Emergency contact: Relationship: Emergency Contact Home Phone: _ Emergency Contact Mobile Phone: Please select your t-shirt size: Small Medium Large XL 2XL How did you hear about Medical Teams International? Colleague Hospital TV/Radio School Church MTI website MTI Staff Volunteer Family Other website Other NGO Work Friend Newspaper Professional Organization Other: Do you have any physical limitations or medical conditions that would prevent you from safely doing the task you are applying for? Yes No If yes, please describe the limitations: Have you ever been charged with or convicted of any crime including either a felony or a misdemeanor? Yes No If yes, please describe when, where, and the nature of the charge: SECTION 2: EMPLOYMENT INFORMATION Retired/Semi-retired? Yes No Company/Agency: Position: Address: City: State/Province: Postal Code: Country: SECTION 3: EDUCATION AND EXPERIENCE Education (Major Subjects): Foreign Languages: Degree of fluency: Novice Intermediate Fluent Previous international or cross-cultural medical, work or mission experience: Country Type of Experience Date Past or present churches, civic or auxiliary affiliations, volunteer experience: Church/Organization: Position:

3 SECTION 4: WHERE WOULD YOU LIKE TO VOLUNTEER? (CHECK ALL THAT APPLY) Portland, OR Redmond, WA Rochester, MN International Team Mobile Dental Program SECTION 4A: OREGON/WASHINGTON (PLEASE COMPLETE THIS SECTION ONLY IF INTERESTED IN VOLUNTEERING IN THE FOLLOWING AREAS) REAL. LIFE. Exhibit Distribution Center Marketing & Development Tour host Sorting/packing medical supplies Special events Delivery/pickup Public speaking General Office Maintenance/repair Graphic Design Data entry /word processing Web Receptionist Translation AVAILABILITY: (A majority of the opportunities are available during normal business hours of M-F 8am 5pm) SECTION 4B: INTERNATIONAL TEAM INTERESTS (PLEASE COMPLETE THIS SECTION ONLY IF INTERESTED IN SERVING ON AN INTERNATIONAL TEAM) To complete your application for review, please send the following along with this application. The Questionnaire and Reference forms can be found at: International volunteer questionnaire Description of work, education, & volunteer history (resume or curriculum vitae) Copy of your medical licenses(s) (if applicable) A photocopy of your passport and a passport-size photo with your name on the back Two professional references using the Medical Teams International Reference Form Full Name on Passport: Expiration Date: / / Please list any countries you have resided in within the last 7 years: Team Types: (Check all that you are interested in and qualified for): Community Health (Medical professionals only) HIV/AIDS Dental (Dental professionals only) Medical (Medical professionals only) Disaster Response (see requirements below) Emergency Medical Care and Preparedness Work /Construction Medical Training Services* *Specialization: Disaster Response Requirements: Current medical licensure MD, DO, PA-C, RN, FNP, ANP, PNP, CNM Previous developing nations work/living experience REGIONS OF INTEREST: Africa Asia Latin America Where most needed Specific Country: AVAILABILITY: Teams serve for 1-3 weeks; Disaster Response teams serve for approximately 3-4 weeks I need at least: 24 hours notice More than 1 month More than 2 months I am available for: 1-2 weeks 2-4 weeks 1-3 months 3-6 months 6-12 months

4 Medical Specialties: CERTIFICATION/LICENSURE: SPECIALTIES: Physician: MD DO Anesthesiology Internal Medicine Pathology Registered nurse Community Health Infectious Disease Pediatrics Dentist: DMD DDS Cardiology Neurology Pharmacology EMT/Paramedic: Level EMS Nutrition Plastic Surgery Nurse Practitioner Endoscopy OB/GYN Radiology Physician Assistant ENT Ophthalmology Trauma Counseling Psychiatrist: MD PhD Family Practice Optometry Urology Psychologist: PhD MA General Surgery Oral Surgery Registered Dental Hygienist HIV/AIDS Orthopedics Therapist: Type: ICU Orthotics Other: CCU Prosthetics Other Specialties: Certification / Medical License #: Issuing State: Certification / Medical License #: Issuing State: (Optional) MTI utilizes volunteers of all faiths and backgrounds. While most of our international partners are open to volunteers of all faiths, some partners request certain religious backgrounds for political and cultural reasons. To help us find the best fit for you and the partner please indicate your current faith: SECTION 4C: MOBILE DENTAL PROGRAM (PLEASE COMPLETE THIS SECTION ONLY IF INTERESTED WITH SERVING IN OUR MOBILE DENTAL PROGRAM) Which Mobile Dental program(s) would you like to serve with: Portland Metro Salem Bend Roseburg Walla Walla Puget Sound Minnesota DDS Dental Assistant Dental Assistant student DMD Dental student Other student RDH RDH student Other: Dental license #: Expires: Specialty: I am licensed in more than one state: Yes No Second license #: _State: Expires: I have malpractice insurance coverage? Yes No If Yes, next renewal date is: I began practicing in (year): My patient preference is: Adults Only Children Only All Patients All volunteers who want to work with children must undergo a criminal background check before volunteering. Procedures I like to do: Procedures I prefer not to do: I would like to volunteer times per week month quarter year These day(s) are best for me: Mon Tues Wed Thurs Fri Sat Dentists: Would you be able to supply your own dental assistant? Yes No

5 GENERAL RELEASE In consideration of Medical Teams International arranging a volunteer assignment for me, and with the intention of binding myself, my heirs, legal representatives, successors and assigns, I hereby expressly RELEASE AND FOREVER DISCHARGE Medical Teams International, its officers, directors, employees, volunteers, agents, legal representatives, insurers, successors, and assigns from any and all claims, demands, damages, liabilities, and causes of action that I now have or may in the future have, whether known or unknown, of whatsoever nature, relating to or arising out of my selection as a volunteer by, or my service as a volunteer with, Medical Teams International whether or not due to Medical Teams International s negligence, strict liability, or any other breach or fault. This includes, but is expressly not limited to, death, bodily injury, personal injury, property damage, loss or theft of property, economic loss, or any other damage, loss or cost. This document shall be construed according to the laws of the state of Oregon. If a dispute should arise with respect to the meaning of any of the terms of this document, the rule of construction that a document is construed against the party preparing such document shall specifically not be applicable to the interpretation of this document. This General Release represents the entire agreement of the parties hereto and supersedes any and all prior or contemporaneous oral or written understandings, statements, representations or promises. All of the terms hereof are contractual and not mere recitals. I acknowledge that I have carefully read this General Release, know and understand the contents thereof, and that this document was freely and voluntarily executed. I acknowledge that I was given the opportunity to seek independent legal counsel on any and all matters herein before I signed this General Release. Volunteer: Date: Parent/Guardian: Date: (Required for volunteers under age 18) CONFIDENTIALITY POLICY In the course of your volunteer work for Medical Teams International, you may have access to or hear about confidential or sensitive information. It is your responsibility not to reveal this information. Information may be used only as it pertains to your work as a volunteer, and it should not be shared with others outside Medical Teams International. Examples of confidential information include but are not limited to donor or volunteer names, telephone numbers, places of employment, financial information, or other information. Breach of this confidentiality policy may require us to terminate your volunteer status. I agree that Medical Teams International may use my name and any photographs and video of me for publicity or promotional purposes without liability or obligation to me. I have read and understand the Medical Teams International volunteer confidentiality policy as written above and agree to adhere to it. Volunteer: Date: _ Parent/Guardian: Date: (Required for volunteers under age 18)