Medical Volunteer Application Please fill out our online application below. Or download the PDF version here. Specialty * Plastic Surgeon Anesthesiologist CRNA Pediatrician OR Nurse PACU Nurse Dentist Dental Hygienist Dental Assistant Speech Pathologist The following documents should be submitted with your application. You will have a chance to upload them at the end of the application, or you can submit them separately via email, fax or standard mail. Current License to Practice Curriculum Vitae PALS Certification (for Pediatricians and PACU Nurses) Diploma Board Certification (for Surgeons, Anesthesiologists, CRNAs and Pediatricians) Cover Letter (Surgeons: include cleft experience; Anesthesiologists: include pediatric experience; PACU Nurses: include pediatric experience) Photocopy of Passport Attestation Form - can be downloaded here: attestation form Please Note: If you are selected to volunteer on a mission, we will need a headshot of you. You may also submit that now. Applicant Name Title Title Name_First * First Name * Name_Last * Last Name * Suffix Suffix Name_First_Preferred Preferred/Nick Name Applicant Address Street1 Street 1 Street2 Street 2 City City State State/Province Postal_Code Zip/Postal Code Country Country PhoneHome Home Phone PhoneCell Cell Phone Email Email_2 Personal Information BirthDate Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year191719181919192019211922192319241925192619271928192919301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018 Gender Passport Name (Complete name as shown on passport) Passport Number Passport Expiry Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year201720182019202020212022202320242025202620272028202920302031203220332034203520362037 Nationality Practice Information Area of Specialty Office or Hospital Name (if applicable) Telephone Travel Info and Trip Fees Alliance for Smiles will cover international travel costs for medical volunteers. Each volunteer is required provide their own transportation to and from the US point of exit (usually San Francisco or Atlanta). Approved mission volunteers are required to pay a $380 Mission Participation Contribution once they have been selected for a mission. If you agree to above, please click Yes Yes No General Information Do you speak any languages besides English? (Indicate level of fluency) Prior Medical Missions You Have Gone On (if any) Are You A Member of Rotary? (Indicate club name/district and how long.) Do you have any medical conditions we should be aware of? Shirt Size XS S M L XL XXL XXXL Other... Shirt Size Other... (In unisex size) Professional ReferencesPlease list two professional references - preferably physicians, dentist or allied health practitioners who are familiar with your work. If possible, include at least one member from the medical staff of each facility at which you have privileges. Reference One Name * Prefix -- Dr.Mr.Ms.Mrs.Prof. Prefix First First Middle name(s) Middle name(s) Last Last Title Title Telephone Email Notes Reference Two Name * Prefix -- Dr.Mr.Ms.Mrs.Prof. Prefix First First Middle name(s) Middle name(s) Last Last Title Title Telephone Email Notes Documentation The following documents must be submitted before you can be approved: Current License to Practice Curriculum Vitae Diploma Board Certification (only for Surgeons, Anesthesiologists, CRNAs and Pediatricians) PALS Certification (only for Pediatricians and PACU Nurses) Cover Letter (Surgeons: include cleft experience; Anesthesiologists: include pediatric experience; PACU Nurses: include pediatric experience) Photocopy of Passport Attestation Form - the form can be downloaded here: https://allianceforsmiles.org/files/pdf/attestation_form.pdf If you don't have all the required documents currently with you, you can submit the application now and send the forms separately via email, fax or standard mail. (You will find mailing address/contact info on the next page after you hit Submit.) To upload the documentation now, please use the button below. Upload Files Upload up to 7 files by clicking the Choose File button. (You can only upload one file at a time). You may also upload all documents together in one Zip file. Once you have completed the application and uploaded all files that you wish to, please agree to the terms and hit the Submit button below. I fully understand that any significant misstatement in or omissions from this application will constitute cause for denial of my application for affiliation with Alliance for Smiles. I hereby affirm that the information I have furnished to Alliance for Smiles on this application and in any accompanying document is true and complete to the best of my knowledge. Do you agree to the above terms? * I Agree CAPTCHAThis question is for testing whether or not you are a human visitor and to prevent automated spam submissions. 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