Project TVD Volunteer Application
Name (Last, First, Middle Initial)
Nickname:
Degree: (example: MD, RN, MBA, PhD...)
Title: (example: Professor, Director, Private Attending...)
Address:
Email:
Office Phone:
Cell Phone:
Healthcare Field: (example: ObGYN, Surgery, Medicine, Public Health...)
Sub-Specialty: (example: Gastroenterology, Hand Surgery...)
Sub-Interests (ex - Bladder Prolapse, Pediatric Hematologic Cancer...) LIST ALL APPLICABLE
Board Certification (if Physician)? or State Licensure (if Allied Health)?
Yes
No
Specialty:
Current Affiliated Institution and Address:
Number of Volunteer Trips Participated (Approx. #):
Previous Volunteer Experience : Include name of organization, location, year of participation, brief description of experience
One Reference: Include Name and Contact Email
Briefly, please describe your expectations, what you think you can add to the trip, and any planned activities for Project TVD:
How did you hear about Project TVD?
Website / Social Media
Conference / Meeting
Referred to Me*
Other**
*If Project TVD was referred to you, please include name of who referred you (If not, write N/A):
**If selected "Other" please explain how you find out about Project TVD (If not, write N/A):
Thank you for filling out this form. If you don’t receive an acknowledgement within 7 working days, please send a follow-up email to Tri Dinh at dinh.tri@mayo.edu
Submit
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