PARTICIPANT APPLICATION

Participant Application

Thank you for your interest in our organization a global medical non-profit.
Name*

First NameLast Name
Date of Birth

DayMonthYear
Date
Email
example@example.com
Phone Number

Country CodeArea CodePhone Number
Professional Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Please list any language you speak other than English.
Training History & Experience

Please provide additional information about your education and previous mission involvment.
Medical School & Location
Medical School Graduation Date

MonthDayYear
Date
Residency Program & Location
Residency Completion Date

MonthDayYear
Date
Fellowship Program & Location
Fellowship Completion Date

MonthDayYear
Date
Current Affiliation
Current Status
Board Certification
State of Valid License
Expiration Date

MonthDayYear
Date
Interests & Capacity

Please let us know how you would like to get involved.
How did you hear about WalkStrong and what are your primary interests within the program?
Are you able to travel and to what specific location(s)?
Preferred Involvement*

MentorshipProgram DevelopmentTeachingEvent Volunteering
Please tell us about any previous mission work you have done, including which organization(s) and when.
WalkStrong Foundation is a non-profit medical organization. Each of our programs has a varying degree of risk. You are expected to assume any and all risks that may result from your participation. Therefore, we must receive a completed and signed partipation form along with a copy of your CV before we can continue to process your application.
Please attach a current copy of your CV.*

Cancelof
Media & Participation Consent

Please acknowledge and let us know if you agree to the following requirements.
I acknowledge and understand that program sites may have a requirement for extended involvement, and my eligibility to participate will require a minimum commitment in advance prior to site approval.
I agree to provide at least a one-page summary of your trip and/or program upon my return.
I agree to give my permission to be photographed by project partners or the media for use in printed materials, through the internet or through other media outlets.
Liability Waiver

Please read the below statements carefully and ensure you understand all risk before signing below.
As a volunteer/participant, I release and hold harmless the Walkstrong Foundation its directors, officers, employees, agents, successors, and assigns from any and all claims, costs, suits, actions, judgments or expenses upon any damage, loss or injury to me or to my property and demands of any nature, past, present, or future, that may result from or be in any way related to activities that may arise from this Walkstrong Foundation event, trip and/or program.

I acknowledge that I am fully aware of any and all risks posed by these activities and that I have no medical condition that prevents me from engaging in them.

In signing below, I acknowledge that I have read and understand this volunteer agreement.
Signature*

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Participant Application

Training History & Experience

Interests & Capacity

Media & Participation Consent

Liability Waiver