NAPS Dental/Medical Volunteer Application
Personal Information
Name
*
Mr.
Ms.
Mrs.
Dr.
Prefix
First Name
Last Name
Professional Abbreviation
Name on Badge
*
Date of Birth
*
-
Month
-
Day
Year
Email
*
example@example.com
Cell Phone Number
*
Please enter a valid phone number.
Shirt Size
X-Small
Small
Medium
Large
X-Large
2X-Large
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Allergies? For each allergy you have please list the SPECIFIC type of allergy, DATE of last reaction and your LEVEL of sensitivity.
*
Please upload a professional picture of yourself.
Dietary preference
*
How did you hear about NAPS?
*
Professional Information
What is your professional background? Please select from the drop-down menu.
Language Fluency (other than English)
*
Please upload copy of your professional license(Dental, Medical etc,) if applicable
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Dental, Medical, Professional License
Cancel
of
Travel Information
Arrival Date
*
-
Month
-
Day
Year
Date
Departure Date
*
-
Month
-
Day
Year
Date
Will you need transportation to and from the airport?
*
Yes
No
Other
Please upload your flight itinerary.
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Cancel
of
Please explain.
Interests and Abilities
1. Have you taken an infection control/blood-borne pathogen certification training?
*
Yes
No
2. Have you been vaccinated for Hepatitis B?
*
Yes
No
3. Are you interested in deploying for disaster relief missions?
*
Yes
No
4. Are you interested in volunteering for international clinics?
*
Yes
No
5. Are you interested in traveling within the United States for clinics?
*
Yes
No
6. Does your employer match your donated time with a financial donation to the non-profit where you volunteer?
*
Yes
No
7. Please list any other additional skills that you have. (Carpentry, plumbing, CDL, etc)
Emergency Contact
Emergency Contact
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Relationship
*
NAPS Volunteer Liability Waiver
Signature
*
Save to Finish Later
Submit
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