Volunteer Application Form: Licensed Provider

Health & Help

Licensed Provider Application Form
Health & Help is made up of dedicated professionals who are passionate about solving global healthcare challenges. Whether working remotely or at our clinics in Guatemala and Nicaragua, our team is committed to making a real difference every day.

We believe that anyone with the right mindset and dedication can help those in need. At Health & Help, doctors, nurses and allied health professionals play a vital role in providing essential medical care, mentoring medical students, and responding to emergencies in underserved communities. Our medically trained volunteers are resilient, compassionate, and ready to make an impact where it’s needed most
Name*

First NameLast Name
Title*
Postion you are titled for and will be acting as in the clinic
Birth Date

MonthDayYear
Email*
example@example.com
Phone Number*

Country CodeArea CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Emergency Contact*

NameRelationship
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
In which clinic would you like to volunteer?
Which of the volunteering activities interest you?
Do you have any volunteering experience? If yes, please describe.
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; HR@he-he.org
Desired Start Date *

MonthDayYear
Date
Desired End Date

MonthDayYear
Date
Additional notes about your schedule
How did you hear about us?
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:

NOTE: If your documents are not scanned clearly, are blurred, or numbers/names can not be read clearly, your application will not be approved so please DOUBLE CHECK the clarity before you upload them!Only PDF files are accepted. Any applications submitted without PDF files will NOT be considered.Files MUST be named correctly in order for us to process your paperwork. Each uploaded document must include: Lastname_Firstname_DocumentFor example, the file name of your resume would read: Lastname_Firstname_Resume
Passport Photo Page (IN COLOR)*

Cancelof
Resumé*

Cancelof
Medical Diploma (IN COLOR)*

Cancelof
Medical license*

Cancelof
For applicants from Guatemala: Constancia de RENAS

Cancelof
The document is available in both English and Spanish, please read and sign the document in the language of your preference.*
Date

MonthDayYear
Date
Signature

Clear
Should be Empty:

Health & Help

When Will You Come?

Spanish Fluency

Files to Upload: