VOLUNTEER APPLICATION
External Providers
Interviewed?
Yes
No
Interview Date
-
Month
-
Day
Year
Date
Past Mission Participation Details
Do not interview?
Yes
Do not interview Details
First Name
*
Last Name
*
Email
*
Phone
*
Address
*
Address (Line 2)
City
*
State
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
OTHER
ZIP Code
Gender
*
Male
Female
Emergency Contact Name:
Emergency Contact Email:
example@example.com
How did you hear about Bridge of Life?
Website
Past TM volunteer
DaVita Presentation or Event
Email
Other
Emergency Contact Phone Number:
-
Area Code
Phone Number
Job Title
*
Specialty (e.g. Internal Medicine, Primary Care, etc.)
*
Certification/Medical License #:
*
Certification/Medical License State:
*
Please Select
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Additional certifications/licenses:
Do you speak or read another language other than English? *
*
Yes
No
If yes, which language other than English do you speak or read?
What is your level of fluency speaking?
Beginner
Intermediate
Advanced
Fluent
What is your level of fluency reading?
Beginner
Intermediate
Advanced
Fluent
Is there another language you speak or read?
What is your level of fluency speaking?
Beginner
Intermediate
Advanced
Fluent
What is your level of fluency reading?
Beginner
Intermediate
Advanced
Fluent
Do you have a current passport ?
*
Yes
No
If yes, in what country was it issued?
If yes, what is the expiration date?
-
Month
-
Day
Year
Date
If no, I agree to obtain a valid passport and/or visa prior to the mission
Yes
No
Have you ever participated in a Bridge of Life medical mission before?
*
Yes
No
If yes, describe the type of work, medical mission, location and your responsibilities.
Have you ever traveled to or volunteered in a country outside of the U.S. before?
*
Yes
No
If yes, describe the type of work/volunteer opportunity, location and your responsibilities.
Why would you like to volunteer with Bridge of Life?*
What volunteer or work experience has helped you to prepare for volunteering with Bridge of Life?
What would you bring to volunteering that would benefit Bridge of Life (program, partners, patients, background/skills, etc.)?
What are your expectations for a medical mission experience? *
I agree to contribute $500 to $1,500 to participate in the mission (required amount varies depending mission length), either through fundraising or my own personal payment, to support mission costs/expenses.
*
Yes
No
I understand that living and working conditions in other countries are much different than those in the U.S., and I am comfortable with those differences.
*
Yes
No
I release Bridge of Life from any and all liability related to my volunteer participation.
*
Yes
No
I understand my work hours will be scheduled upon arrival and may change daily to meet mission needs.
*
Yes
No
Submit
Should be Empty: