VOLUNTEER APPLICATION Looking to join our team? Fill out the application below. Name * First Name Last Name Professional Title * MD/DO PA Psychologist NP Resident Medical Student Non-Clinical Volunteer Specialty * Emergency Medicine Internal Medicine Family Medicine Pediatrics OB-Gyn Surgery Other N/A Residency Year 1 2 3 4+ Email * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Gender * Male Female Other Age * Shirt Size * X-S S M L XL XX-L Other Languages Spoken * English Arabic Spanish French Shona Irdu Hindi Nepali Other Desired Mission * Choose all locations of interest (This does not commit you to any specific trips). Dominican Republic Guatemala Haiti Jordan Nepal Pakistan Ukraine Zimbabwe How did you learn about Emergency Project * Please specify the name if you were referred by a Family/Friend/Colleague, Partner Organization, Media Source Emergency Contact * First Name Last Name * Phone Number (###) ### #### * Email Documents Required Please upload all the documents listed below. For each file name, please rename to include "FirstName_LastName" and the corresponding file type. Example: Emergency_Project_Picture.jpg Picture * FileField; MaxSize= 10000KB; Passport Scan * FileField; MaxSize= 10000KB; License/Residency Letter * FileField; MaxSize= 10000KB; CV * FileField; MaxSize= 10000KB; Signed Waiver * FileField; MaxSize= 10000KB; A letter of good health from a physician may be required closer to the mission timeframe to volunteer. * I understand I have read and signed the liability waiver. * I understand Only fully completed forms, with all the proper required documents uploaded, are received and acknowledged. * I understand Thank you again for you interest. We will reach out once we have revewed your application. Please conact us at info@emergecyproject.org for any questions or concerns. Waiver Form
