INTERNATIONAL MEDICAL VOLUNTEER APPLICATION

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1.
Full Name
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2.
Gender
Female
Male
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3.
Date of Birth
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4.
Country
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5.
Phone Number
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6.
Email Address
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7.
Home Address
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8.
WORK INFORMATION
Name of Work Hospital
Name of Work Hospital
Positional Title
Positional Title
Work Address
Work Address
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9.
EMERGENCY CONTACT
Name
Name
Contact Number
Contact Number
Relationship
Relationship
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10.
Please select from the following specialties.
Surgeon
(Plastic, ENT, Oral or Pediatric surgeon)
Operating Room Nurse
Anesthesiologist
Recovery Room Nurse
Pediatric Intensivist
Pre/Post Op Nurse
Pediatrician
Peds Nurse
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12.
Please indicate which types of patients/programs you  have had experience with in the last 3 - 5 years.【Multiple】
Choose at least ONE option
Pediatrics (0-6 years old)
Youth (7-14 years old)
Adult (over 14 years old)
Burns
Orthopedics
Craniofacial
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13.
Current job description
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14.
Do you have registered license?
If YES, please fill in your specialty and certified date.
Yes,
No
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15.
Do you still practice in your stated specialty?
Yes
No
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16.
Have your medical privileges ever been suspended?
If YES, please explain.
Yes,
No
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17.
Do you have BLS certification?
If YES, please write the certified date.
Yes,
No
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18.
Do you have PALS certification?
If YES, please write the certified date.
Yes,
No
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19.
Do you have ACLS certification?
If YES, please write the certified date.
Yes,
No
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20.
Have you ever participated in any overseas medical/healthcare work?
If YES, please explain.
Yes,
No
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21.
Foreign languages and sign language (please indicate level of fluency) :
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22.
Please provide information for an individual from within your specialty who can attest to your clinical ability, professionalism, and ability to work as a part of a team in high-stress situations.
One Reference must be needed and he/she should be our current credentialed volunteer.
Name
Name
Position
Position
Company/Hospital
Company/Hospital
City, State, Country
City, State, Country
Telephone Number
Telephone Number
Email
Email
For how long did you work closely with this reference?
For how long did you work closely with this reference?
In what capacity did you work with this reference?
In what capacity did you work with this reference?
Is this reference a Smile Mission volunteer?
Is this reference a Smile Mission volunteer?
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23.
Please upload your current curriculum vitae/resume.
选择文件( 不超过4M )
24.
Please upload your current copy of Board certification (or equivalent ).
选择文件( 不超过4M )
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25.
Please upload your Passport.
选择文件( 不超过4M )
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26.
Please upload your Passport.
选择文件( 不超过4M )
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27.
Please upload your ID.
选择文件( 不超过4M )
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28.
Please upload your current copy of diplomas and degrees.
选择文件( 不超过4M )
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