Operation of Hope | Medical Mission Anesthesia Volunteer Application

MEDICAL MISSION ANESTHESIA VOLUNTEER APPLICATION

Contact Information

First Name
Middle Name
Last Name
Home Phone
Work Phone
Cell
Fax
Email
Nearest airport to you
Home Address
City
State
Zip
Nationality
Preferred Mailing Address: Home Work

Current Employment

Present Position
How long?
Employer
Address
City
State
Zip
Country
Phone
Direct Supervisor

Emergency Contact Info

Emergency Contact
Relationship to you
Phone
Email
Address
City
State
Zip

Passport Info

Passport Number
Birth Date
Name as it appears on your passport, exactly
Passport Expiration Date
City passport was issued in

Specializations

Please select from the following specialties: Anesthesiologist
Pediatric Anesthesiologist
Nurse Anesthetist
Current Experience: Please indicate which types of patients / programs you have had experience with in the last 3-5 years, and describe your current work:
Pediatrics (0-6 years old)
Youth (7-14 years old)
Adults (over 14 years old)
Burns
Orthopedics
Craniofacial
Please briefly describe the nature of your current work:
Please provide details and dates of any Pediatric Fellowships you are currently in or have completed:

Specialty Training	School / Hospital
Cleft Lip
Cleft Palate
Burns
Flaps
Microsurgery
Peds Anesthesia
Other

Board Certified: Yes Specialty: Date:
No
Board Eligible: Yes Specialty: Date:
No
Do you still practice in your stated specialty? Yes No
Have your medical privileges ever been suspended? Yes No
If yes, please explain:

Other Experience

PALS Certification: Yes Certification Date:
No
ACLS Certification: Yes Certification Date:
No
Have you ever participated in any overseas/health care work? Yes No
If yes, please explain with the name of organization:
Please give details:
Why do you want to go on a mission?
Why do you think you make a good volunteer?

Additional Info

Foreign language and sign language (please indicate level of fluency):
How much notice do you need to join a mission team?

Medical & Dietary Info

Have you had shots for Hepatitis A and Hepatitis B?
Hepatitis A
Hepatitis B
Do you have any dietary needs? If so, please explain:
Any issues we need to be aware of?
Do you have any medical issues that we need to be aware of? If so, please explain:

Height and Weight

This is for purposes of team clothing such as polo shirts, t-shirts, etc.

Height
Size of polo shirt

Signature

By filling out the information below, you are electronically signing this form.

Application Process

Once we receive your application, we will contact you either by e-mail or by telephone. If selected as a volunteer, you will need to send the following information and/or documents to our mail office within 2 weeks of notification (address listed below). So please be able to have this information and/or documents ready:

1. Current Curriculum Vitae / Resume
2. Current copies of Licensure
3. Current copy of Board Certification (if applicable)
4. Copies of diplomas and degrees
5. Current copy of PALS certification (if applicable)
6. Current copy of ACLS certification (if applicable)
7. A photocopy of your current passport
8. Three (3) letters of recommendation form individuals in your specialty (CRNA Applicants: one of your letters of recommendation MUST come from the head of your Anesthesiology Department).
9. Please submit (2) two passport size photographs (not photocopies)

If any of the above information is not in the application packet, the application is considered incomplete. You will be notified if your application is incomplete. Completed application packets will be sent to our main office at which time you may be interviewed by telephone or asked to submit additional information. Operation of Hope will inform you of the results of your application.

If chosen for a volunteer position, the rest of the packet with the above mentioned items are due within a (2) two week time frame. If you are chosen for a medical mission, all of your work will be done on a volunteer basis. You will provide all transportations costs to the mission site and Operation of Hope will pay for lodging, food and to a designated weekend away during the duration of the mission. If chosen, we ask that 25-50 names (either email and or mailing address) to family and friends be collected for our database.

I have read the above and certify that the foregoing is true, correct and complete. I shall promptly inform Operation of Hope if there is any change to the facts herein.

Signature