Volunteer Registration Form: Licensed Providers

Volunteer with Floating Doctors

Licensed Provider Registration Form
Name*

First NameMiddle NameLast Name
E-mail*
Birth Date*

MonthDayYear
Height (for boat calculations). Use arrows to switch between Imperial and Metric.*
Weight (for boat calculations). Use arrows to switch between Imperial and Metric.*
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
How did you hear about us?*
If former/current staff or volunteer, who?
If other, please specify:
If friend/professor, who?
When Will You Come?

Start Date must be a Sunday. End Date may be a Friday or Saturday. If your dates are firm, please email us first to check if we have space before applying; Volunteerinfo@FloatingDoctors.com
Desired Start Date

YearMonthDay
Desired End Date

YearMonthDay
Any extra information about your desired dates
Medical History
Medical History*

Back injuries or back painHeart DiseaseDiabetesLung DiseaseHerniaBroken or dislocated limbs, shoulders, hips, fingers, etc.Severe seasicknessAlcoholism, drug dependenceOther injury or disease that may be aggravated by or affect performance of dutiesAllergies, food/diet restrictions, substance sensitivities (smoke, noise, dust, etc)None
Please Specify Allergies and if you carry an EpiPen:*
Have you ever had to seek medical attention for an allergic reaction to food, medication, or anything else, or have you ever had to be treated by a doctor for an acute exacerbation of a chronic medical condition that you currently still have:*
If you are on ANY medications (prescription or otherwise) please list the names, dosage and indications:*
Travel Health Insurance (Please Provide Company Name and Policy Number):
Other Considerations:
Criminal Background Disclosure
Have you ever been convicted of, pled guilty or no contest to:*

Any non-violent misdemeanor within the past fifteen (15) years (other than minor traffic violations)Any misdemeanor crime involving violence against another person, fraud or theftAny felony convictionNone of the above
If you answered yes to any of the above categories, please explain below:
NOTE: When reviewing prior criminal convictions, Floating Doctors considers the totality of the circumstances: including additional factors such as the seriousness of the crime, the time that has passed since the conviction, and any evidence of rehabilitation the applicant submits. However, if you misrepresent, omit or lie on your application, your application may be denied.
Emergency Contact Information
In case of emergency, please provide the individual you would like contacted (First and Last Name)*
Phone Number*

Area CodePhone Number
E-mail*
Letter of Intent
Please write a letter of intent outlining what you feel you would give to a program such as ours, as well as what you feel you would take away from the experience*
Spanish Fluency
Please provide your estimated level of fluency in Spanish. Please note that it is not required that you are fluent in Spanish. This information helps us ensure we have enough Spanish-speakers at any given time.*
Files to upload:
Medical License (IN COLOR) *Your license MUST be valid throughout the dates you volunteer with us. If your license will expire prior to your leaving us, you will need to submit your renewed licensed as you get closer to arrival.*

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Passport Photo Page (IN COLOR)*

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ONE of the following to provide information of previous convictions or investigations relating to child protection: Police check, LiveScan, https://www.npdb.hrsa.gov check, copy of Disclosure and Barring Service (DBS) or Criminal Records Bureau (CRB) check from country of origin*

Choose File

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Diploma (IN COLOR)*

Choose File

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Résumé / CV (Please limit to 2 pages)*

Choose File

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Letter of Recommendation

Choose File

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Terms & Conditions
Proof of Payment of Application Fee*

Browse Files

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Floating Doctors is conducting a research project to better understand the effect of volunteering on our volunteers. This involves a pre and post-volunteer survey. Please select an option to indicate if you are willing to be contacted about participating.

I AGREE to be contacted.I DO NOT AGREE to be contacted.
Travel Health Insurance*

I have health coverage abroad and have listed the policy name and number aboveI do not currently have health coverage abroad but will secure travel health insurance prior to arrival in Bocas del Toro. I understand that I am responsible for securing medical coverage in the case of any incident while volunteering with Floating Doctors.
Signature*

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Volunteer with Floating Doctors

When Will You Come?

Medical History

Criminal Background Disclosure

Emergency Contact Information

Letter of Intent

Spanish Fluency

Files to upload:

Terms & Conditions