External Providers - Volunteer Application

VOLUNTEER APPLICATION

External Providers

Interviewed?

Interview Date

Date

Past Mission Participation Details

Do not interview?

Do not interview Details

First Name

Last Name

Email

Phone

Address

Address (Line 2)

City

State

ZIP Code

Gender

Emergency Contact Name:

Emergency Contact Email:

example@example.com

How did you hear about Bridge of Life?

Emergency Contact Phone Number:

Area CodePhone Number

Job Title

Specialty (e.g. Internal Medicine, Primary Care, etc.)

Certification/Medical License #:

Certification/Medical License State:

Additional certifications/licenses:

Do you speak or read another language other than English? *

If yes, which language other than English do you speak or read?

What is your level of fluency speaking?

What is your level of fluency reading?

Is there another language you speak or read?

What is your level of fluency speaking?

What is your level of fluency reading?

Do you have a current passport ?

If yes, in what country was it issued?

If yes, what is the expiration date?

Date

If no, I agree to obtain a valid passport and/or visa prior to the mission

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

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?

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.

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.

I release Bridge of Life from any and all liability related to my volunteer participation.

I understand my work hours will be scheduled upon arrival and may change daily to meet mission needs.