Application: Team Lead Fellowship

Floating Doctors Fellowship

Team Lead Application Form
Name*

First NameMiddle NameLast Name
E-mail*
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
How did you hear about us?
If Current or Former Staff or Volunteer, who?
For which positions are you applying?
When Are You Available?
Desired Start Date

MonthDayYear
Desired End Date

MonthDayYear
Any extra information about your desired dates
Medical History
Medical History

Back injuries or back painHeart DiseaseDiabetesLung DiseaseHerniaBroken or dislocated limbs, shoulders, hips, fingers, etc.Severe seasicknessAlcoholism, drug dependenceOther injury or disease that may be aggravated by or affect performance of dutiesAllergies, food/diet restrictions, substance sensitivities (smoke, noise, dust, etc)None
Please Specify Allergies:
Have you ever had to seek medical attention for an allergic reaction to food, medication, or anything else, or have you ever had to be treated by a doctor for an acute exacerbation of a chronic medical condition that you currently still have:
If you are on ANY medications (prescription or otherwise) please list the names, dosage and indications:
Travel Health Insurance (Please Provide Company Name and Policy Number):
Other Considerations:
Criminal Background Disclosure
Have you ever been convicted of, pled guilty or no contest to:

Any non-violent misdemeanor within the past fifteen (15) years (other than minor traffic violations)Any misdemeanor crime involving violence against another person, fraud or theftAny felony conviction
If you answered yes to any of the above categories, please explain below:
NOTE: When reviewing prior criminal convictions, Floating Doctors considers the totality of the circumstances: including additional factors such as the seriousness of the crime, the time that has passed since the conviction, and any evidence of rehabilitation the applicant submits. However, if you misrepresent, omit or lie on your application, you application may be denied.
Emergency Contact Information:
In case of emergency, please provide the individual you would like contacted.*

First NameLast Name
Phone Number*

Area CodePhone Number
E-mail*
Letter of Intent:
Please write a letter of intent outlining what you feel you would give to a program such as ours, as well as what you feel you would take away from the experience*
Please provide your field and level of education*
Application Questions
The Floating Doctors mission is to reduce the present and future burden of disease in the developing world while implementing improvements in health care delivery. How have your past experiences informed your commitment to this mission?*
As a Team Lead, you will be in a position to significantly influence the organization. What perspectives do you bring? What can you add to Floating Doctors?*
Other Considerations
Please provide any additional information regarding your application, including whether you will be in this position for university credit.*
Spanish Fluency:
Please provide your estimated level of fluency in Spanish.*
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_Document

For example, the file name of your resume would read: Lastname_Firstname_Document
Passport Photo Page (in color)*

Upload a File

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Résumé / CV (Please limit to 2 pages)*

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Letter of Recommendation*

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APOSTILLED Diploma (IN COLOR) Apostilles are a way of certifying that documents are genuine and can be legally recognized in another country. Panama requires foreign diplomas to be apostilled. An apostille in NOT the same as a document authentication. Please refer to your local government for instructions on how to receive an apostille.

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APOSTILLED Medical License (IN COLOR) Apostilles are a way of certifying that documents are genuine and can be legally recognized in another country. Panama requires foreign medical licenses to be apostilled in order to cover our volunteers for medical liability. An apostille in NOT the same as a document authentication. Please refer to your local government for instructions on how to receive an apostille.

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ONE of the following to provide information of previous convictions or investigations relating to child protection: Police check, LiveScan, https://www.npdb.hrsa.gov check, copy of Disclosure and Barring Service (DBS) or Criminal Records Bureau (CRB) check from country of origin:*

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Terms & Conditions

Agreement to the following Terms and Conditions is required for application submission and volunteering with Floating Doctors.
Travel Health Insurance

I have health coverage abroad and have listed the policy name and number aboveI do not currently have health coverage abroad but will secure travel health insurance prior to arrival in Bocas del Toro. I understand that I am responsible for securing medical coverage in the case of any incident while volunteering with Floating Doctors.
E-Signature*

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Security Key (Enter the message as it's shown)*
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Floating Doctors Fellowship

When Are You Available?

Medical History

Criminal Background Disclosure

Emergency Contact Information:

Letter of Intent:

Application Questions

Other Considerations

Spanish Fluency:

Files to upload:

Terms & Conditions