Hope Smiles Global Dental Serve Trip Interest Form

1

Legal Name* This field is required.

Prefix

First Name

Last Name

2

We are excited to serve with you! What type of volunteer are you?* This field is required.

Dentist

Dental Assistant

Dental Hygienist

Dental Student

Other

3

Please provide more information on the type of volunteer you are?* This field is required.

4

If you are a specialist, please list your speciality:If this does not apply, press "next"

5

What type of student are you?* This field is required.

Dental School Student

RDA Student

RDH Student

Other

7

Where are you enrolled in school?

8

Are you licensed to deliver local anesthesia* This field is required.

YESNO

9

If you are currently employed, please list your employer or practice affiliation:

10

Please upload a copy of your current license/registration* This field is required.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

11

Phone Number

Area Code

Phone Number

12

What's the best email address for you?* This field is required.

13

Gender

Female

Male

14

What is your birthday?

Date

15

Have you been on a Hope Smiles trip before?* This field is required.

YESNO

16

What countries have you visited in the last 10 years?* This field is required.If this doesn't apply, please put "none" in the text box.

17

What month would you be interested in joining us on a Serve Trip?

June 2026

July 2026

I'm open to either!

18

How did you hear about this opportunity?* This field is required.

19

Do you have any health related limitations to your involvement with your team's work on a Global Dental Serve Trip?* This field is required.

Nope, I am good to go!

Yes, but I am still interested!

20

In brief, please explain your possible health related limitations.