Stage 1: Partner for Surgery Volunteer Application

Stage 1: Partner for Surgery Volunteer Application
PERSONAL INFORMATION
Name as shown on passport*

First Name Middle Name Last Name
Passport number:*
Date of Birth*

MonthDay Year
Date
Nationality*
CONTACT INFORMATION
Home Address*

Street Address

Street Address Line 2

City State / Province

Country Code Country
Mobile*

Area Code Phone Number
Home Phone

Area Code Phone Number
E-mail*

Confirmation Email example@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 Name Last Name
Relationship*
Emergency Contact number*

Area Code Phone Number
Are you a:*

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

Browse Files
(Not required for Rural Missions) Copy can also be sent via email at ariel@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 ariel@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 ariel@companerogt.org Cancelof
Name of the team you will be a part of:*
What kind of Mission are you applying to:*

Surgical Medical MissionRural Medical Mission
Are you applying as:

SurgeonAnesthesiologistNon-Medical Volunteer
Are you applying as:

LeaderParticipant
What team are you a part of:
Are you applying as:

DoctorNurseNon-Medical Volunteer
Mission Start Date*

MonthDay Year
Date
Mission EndDate*

MonthDay Year
Date
Travel Start Date*

MonthDay Year
Date
Travel End Date*

MonthDay Year
End Date
List your medical specialty(ies)*
Are you able to administer VIA/Cryo? (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.
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Stage 1: Partner for Surgery Volunteer Application

PERSONAL INFORMATION

CONTACT INFORMATION

PARTICIPATION AGREEMENT

PROOF OF INSURANCE AND EMERGENCY EVACUATION COVERAGE

Thank you for partnering with us!