Surgical/Medical Volunteer
Personal Information
Your Name
*
First Name
Middle Name
Grand Father
Last Name
Blood Type
*
Country of Birth
*
City of Birth
*
Nationality
*
Do You have a Palestinian ID
*
Please Select
Yes
No
Phone Number
*
-
Area Code
Phone Number
WhatsApp
*
Email
*
example@example.com
Place of Resident:
*
Please Select
Global
Jordan
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Language
You are
*
Active
Retired
Medical Mission Information
Profession
*
Doctor
Nurse
ICU Nurse
Anesthesiologist
Technician
Paramedic
Type of Mission
Surgical
Medical
Surgical Specialty
Adult General surgery
Cardiac Surgery
Cleft Lip and Palate
Dentist
ENT
General Surgery
Gynecology
Hand Surgeon
Maxillofacial
Mental Health Program
Neurosurgery
Nephrology
Oncology
Ophthalmic Surgery
Orthopedic Surgery
Pediatric Cardiology
Pediatric Surgery
Plastic or Reconstructive
Pulmonology
Scoliosis
Tracheal and Respiratory
Thoracic Surgery
Total Hip and Knee Replacement
Urology
Vascular Surgery
Specific Areas of Expertise within Specialty
*
Are you able to bring an anesthesiologist and scrub nurse to come with you?
YES
NO
Medical Specialty
Oncology/Hematology
Nephrology
OB/GYN
Pediatrics
Pediatric Cardiology
Neurology
Gastroenterology
Endocrinology
Immunology
Infectious Disease
Rheumatology
Dermatology
Psychology
Ophthalmology
Pulmonology
When are you able to travel?
*
-
Month
-
Day
Year
Date Picker Icon
Departure
-
Month
-
Day
Year
Date Picker Icon
Mission Location
*
Gaza
West Bank
Jordan
Lebanon
For how long
one week
two weeks
one month
longer
*** For Gaza, 1month minimum commitment
Experience
Have you volunteered on a mission before?
YES
NO
When and Where
Was it with another NGO?
YES
NO
With who?
Have you previously been denied entry (on missions to Gaza or West Bank)?
*
Please Select
Yes
No
Years Post-Training
1-5
6-10
11-20
21-30
Do you Speak Other Languages?
YES
NO
If yes, which?
Arabic
English
Italian
French
German
Hebrew
Dutch
Mandarin
Cantonese
Japanese
Spanish
Urdo
Farsi
Other
Are you comfortable training on your mission?
YES
NO
If no, why not?
Your Current Work Status
Private Hospital
Public Hospital
University Hospital
NGO Hospital
Clinic
Retired
How did you hear about PCRF
Friend/Colleague
NGO
Web Search
Medical Society
Other
Documents Required
Upload Your CV
*
Upload CV
Cancel
of
Upload your passport
Upload passport
Cancel
of
Upload Medical/Dental Diploma
*
Upload
Cancel
of
Upload headshot photo
*
Upload
Cancel
of
Upload Residency training Certificate
Upload
Cancel
of
Upload Fellowship Training certificate (if Any)
Upload
Cancel
of
Upload Board Certification Certificate
*
Upload
Cancel
of
Upload Current License to Practice in Home Country
*
Upload
Cancel
of
Personal Emergency Contact Details
Emergency Contact Name
First Name
Last Name
Relationship to Volunteer
Emergency Contact Phone Number
-
Area Code
Phone Number
Save
Submit
Should be Empty: