Volunteer Travel Application
Name
*
First Name
Last Name
Phone Number
*
-
Country Code
-
Area Code
Phone Number
Email
*
example@example.com
Family Member Volunteer Names
We welcome spouses and children 12 and up as general volunteers. If you would like family members to accompany you on the mission, please provide their names above.
What are your dates of travel?
Use this format: MM/DD/YYYY - MM/DD/YYYY
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please select the Volunteer Role that best describes you:
*
Surgeon
Anesthesiologist
CRNA
Optometrist
Scrub Tech
Scrub Nurse
Physician Assistant
OR Circulator
Pre-Op/PACU Nurse
Ophthalmic Tech
General Volunteer
Other
Surgeon Specialty
Emergency Contact
*
First Name
Last Name
Emergency Contact Phone
*
-
Country Code
-
Area Code
Phone Number
Emergency Contact Email
*
example@example.com
Dietary Needs / Allergies
*
Enter "none" if you have no special dietary needs / allergies
Have you been part of an ACE Global Teaching Travel Team before?
*
Yes
No
Please fill out and upload the following with as much detail as possible.
Medical Credentials/Licensing
*
Browse Files
Drag and drop files here
Choose a file
Please upload all current applicable medical credentials and/or licensing (copy of License and copy of Diploma)
Cancel
of
No medical credentials or licensing
I do not have any medical credentials or licensing.
Passport
*
Browse Files
Drag and drop files here
Choose a file
Please upload a photo of your valid passport. If you will accompanied by any family members, please also upload a photo of their passports. If your passport is not valid at this time, please take the opportunity to renew/apply for one as it will be required for travel.
Cancel
of
Experience & Qualifications
*
Please give a brief explanation of your professional experience and qualifications to take on this volunteer role. If you are a surgeon, please give a breakdown of types of cases you handle in your home practice.
Personal Statement
*
Please give a brief statement of why you are applying to volunteer with ACE Global. What do you hope to give and/or gain through the experience?
Do you have past medical mission or humanitarian aid experience?
*
Please explain any experience you may have working/volunteering outside your home practice that may apply.
Do you speak another language other than English, how fluently?
*
Anything else you would like us to know and/or consider?
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