Operation Walk Volunteer - General Application

Volunteer General Application
Name*

First NameMiddle NameLast Name
E-mail*
Telephone*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Passport #
Passport Expiration Date*

MonthDayYear
Emergency Contact*

First NameLast Name
Emergency Contact Email
Emergency Contact Phone

Area CodePhone Number
Position you are interested in*

AnesthesiologistPhysical TherapistPhysician AssistantCentral ProcessingSurgical TechnicianSurgeonCirculating Nurse in OR (RN)Floor Nurse (RN)Pre/Post Operative Nurse (must have critical care experience)Other
License Specialty (If Applicable)
Expiration Date (If Applicable)

MonthDayYear
Are you a new Operation Walk Chicago Volunteer?*

YesNo
List last 3 jobs relevant to medical trip (most recent first) *
List 1 or 2 references with contact information (supervisor/ colleague)*
Highest Education level - Include copy of Graduate School Diploma ( nursing or medical or college)* if applicable *
Upload Diploma Here*

Upload a File

Cancelof
Other Volunteer Experience - List any applicable special skills*
Languages Spoken:
Motivation - Explain why are you interested in joining Operation Walk Chicago*
Agreement:
- You have never been convicted of any felony.
- A copy of your current medical license and passport (valid within 6 months of travel times) is required.
- Operation Walk Chicago missions last 9 to 14 days. As an Operation Walk Chicago volunteer, you are committing your time to the entire mission.
- Operation Walk Chicago plane tickets are non-refundable and any fees resulting from changes/cancellations are your responsibility.
- Travel and medical insurance as well immunizations are your responsibility.
- A flat fee of $500 is required of all non-physician volunteers to help cover airfare, lodging and ground transportation.
- As a volunteer, you are financially responsible for any costs incurred for visa, immunizations, individual dinners, hotel incidentals.
Do you understand and accept this agreement?*

YesNo
Disclosure:

Completion of this application does not guarantee selection for any specific trip. Upon receipt of this application, we will include you in our pool of volunteers and you will receive general e-mail communications as well as notification for the next trip opportunity. You are welcome to apply for any missions but please understand that space is limited and teams are chosen based on a number of variables.
Any questions, please contact Sophie Sauser at ssauser@operationwalkchicago.com

Thank you for volunteering!
Name

First NameLast Name
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Volunteer General Application