Volunteer Application Form

Volunteer Application Form
PERSONAL INFORMATION
Name as shown on passport*

First NameMiddle NameLast Name
Passport number:*
Date of Birth*

MonthDayYear
Date
Nationality*
CONTACT INFORMATION
Home Address*

Street Address

Street Address Line 2

CityState / Province

Country CodeCountry
Mobile*

Area CodePhone Number
Home Phone

Area CodePhone Number
E-mail*

Confirmation Emailexample@example.com
Social Media Handles if you want us to tag you:
Social Media Handles we can use to tag you during our mission
Emergency Contact*

First NameLast Name
Relationship*
Emergency Contact number*

Area CodePhone Number
MISSION REGISTRATION

(Information pertinent to the mission)
Are you a:*

Doctor (Rural Missions)Surgeon (Surgical Missions)NurseAnesthesiologistNon - Medical VolunteerOther
Attach Notarized copy of the Medical School diploma

Browse Files
(Not required for Rural Missions) Copy can also be sent via email at carlos@companerogt.org Cancelof
Attach Notarized copy of the specialty diploma

Browse Files
(Not required for Rural Missions) Copy can also be sent via email at carlos@companerogt.org Cancelof
Attach Notarized copy of active practice License

Browse Files
(Not required for Rural Missions) Copy can also be sent via email at carlos@companerogt.org Cancelof
Are you coming as:*

Part of a TeamIndividual
What kind of Mission are you applying to:*

Surgical Medical MissionRural Medical Mission
What Surgical team are you a part of:
What Rural Mission are you a part of:
Name of the team you will be a part of:
Are you applying as:

Surgeon (Surgical Mission)Doctor (Rural Missions)AnesthesiologistNurseNon-Medical VolunteerOther
Are you applying as:

LeaderParticipant
Are you applying as:

DoctorNurseNon-Medical Volunteer
Mission Start Date*

MonthDayYear
Date
Mission EndDate*

MonthDayYear
Date
Travel Start Date*

MonthDayYear
Date
Travel End Date*

MonthDayYear
End Date
List your medical specialty(ies)*
Are you able to administer VIA/Cryo? (Rural Missions Gynecologists only)

YesNo
Indicate any specific medical conditions that could affect your participation: (i.e. allergies): (Indicate in the field below if you don't have any medical conditions)*
Level of Spanish fluency: (not required for participation)*
PARTICIPATION AGREEMENT
PROOF OF INSURANCE AND EMERGENCY EVACUATION COVERAGE
Company Name:
Policy Number
Phone Number
Signature*
Thank you for partnering with us!

Together we are improving health, empowering communities, overcoming barriers.
Should be Empty:

Volunteer Application Form

PERSONAL INFORMATION

CONTACT INFORMATION

MISSION REGISTRATION

PARTICIPATION AGREEMENT

PROOF OF INSURANCE AND EMERGENCY EVACUATION COVERAGE

Thank you for partnering with us!