Operation of Hope | Medical Mission Nursing Volunteer Application

MEDICAL MISSION NURSING 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
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

Nursing Experience

Please indicate your Level of Nursing: RN BSN MSN Nurse Practitioner
How long have you worked as a nurse?
In what area would you be most qualified to volunteer? Operating Room Recovery Room Floor
Please indicate which types of patients/programs you have had experience with in the past 3-5 years:
Pediatrics (0-6 years old)
Youth (7-14 years old)
Adults (over 14 years old)
Burns
Craniofacial
Please briefly describe the nature of your current work:
Instructor Certification - If you are a certified instructor for CPR or PALS, please check the appropriate box(es):
CPR Instructor
PALS Instructor
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?
Has your nursing license ever been suspended or revoked? Yes No
If yes, please explain:
Please indicate your level of starting IV's, if any, in children 1 month old and older:

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 Licensure
3. Current Board Certified (if applicable)
4. Current CPR / BLS Certification (if applicable)
5. Current PALS Certification (if applicable)
6. Copies of diplomas
7. A photocopy of your current passport
8. Three (3) letters of recommendation: The three letters need to specifically explain your ability to work as a part of a team in high-stress situations and provide a brief evaluation regarding your current field of work. One of these letters must be from the head of the department where you operate or practice. This is a professional medical application; letters should be typed on letterhead and have the author's contact information.
9. Please submit (2) two passport size photographs (not photocopies)

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