International Mission - Volunteer Application

VOLUNTEER APPLICATION

International Village Service Trip

(includes International Dialysis Capacity, PD Room Construction, Surgical, and Chronic Disease Screenings)

Interviewed?

YesNo
Interview Date

MonthDayYear
Date
Past Mission Participation Details
Do not interview?

Yes
Do not interview Details
First Name*
Last Name*
Work E-mail*
Other E-mail
Phone*
Gender*

MaleFemale
Address*
Address (Line 2)
City*
State
ZIP Code
Emergency Contact Name:
Emergency Contact Email:
example@example.com
Emergency Contact Phone Number:

Area CodePhone Number
Job Title*
Facility/ Department/ Division Name*
Facility Address
City
State
Zip Code
Supervisor Name and Title*
Supervisor E-mail Address*
Phone*
Employment Start Date

MonthDayYear
Date
Area of Interest

Dialysis CapacityPrimary CareScreening and EducationSurgical - AV FistulaPD Room ConstructionOther
Certification/Medical License # (if applicable):
State (if applicable)
Additional certifications or specialties (if applicable)
Region of Interest

AfricaAsiaLatin AmericaWhere most needed
Do you speak or read another language other than English? **

YesNo
If yes, which language other than English do you speak or read?
What is your level of fluency speaking?

BeginnerIntermediateAdvancedFluent
What is your level of fluency reading?

BeginnerIntermediateAdvancedFluent
Is there another language you speak or read?
What is your level of fluency speaking?

BeginnerIntermediateAdvancedFluent
What is your level of fluency reading?

BeginnerIntermediateAdvancedFluent
Do you have a current passport ?*

YesNo
If yes, what country was it issued?
If yes, what is the expiration date of your passport?

MonthDayYear
Date
If no, I agree to obtain a Passport and/or Visa prior to the mission

YesNo
Have you ever participated in a Bridge of Life medical mission before?*

YesNo
If yes, describe the type of work, medical mission, location and responsibilities.
Have you ever traveled to or volunteered in a country outside of the U.S. before?*

YesNo
If yes, describe the type of work/volunteer opportunity, location and responsibilities.
Why are you volunteering for this international mission*
What volunteer or work experience has helped you to prepare for this position?
What would you bring to your position that would benefit Bridge of Life (program, partners, patients)?
What are your expectations for a medical mission experience? *
Dialysis Capacity Missions

Please answer the following 4 questions only if you are interested in a Dialysis Capacity mission.
Describe your areas of dialysis expertise.
What type(s) of dialysis machine(s) do you have experience with (i.e. Fresenius, Gambro Phoenix, Nipro, etc.)? Please be specific.
Do you have experience as a trainer/proctor?

YesNo
How comfortable are you in a training/proctor position?

very comfortablecomfortablesomewhat comfortablenot very comfortable
Please describe your training experience (including # of people precepted, when, etc.)
All applicants, please answer the following questions.
I am currently a full-time teammate and have been employed by DaVita for at least 6 months*

YesNo
I have accrued PTO (40 hours) and am willing to contribute some of those days in exchange for the ability to participate in the program.*

YesNo
I agree to fundraise $1000 to $2,000 to participate in the mission (required amount varies depending on length of mission)*

YesNo
I understand that living & working conditions in other countries are much different than those in the U.S., and I am comfortable with those differences*

YesNo
I release Bridge of Life from any and all liability related to my participation in this program*

YesNo
I understand my hours of work will be scheduled upon arrival and may be changed daily to meet the needs of the mission*

YesNo
How did you hear about BOL?
Should be Empty:

Dialysis Capacity Missions

All applicants, please answer the following questions.