How to Apply | Global Clinic

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UPCOMING HEALTH MISSIONS:

Dominican Republic – Santiago – Medical Mission – April 22nd to 30th, 1017 Please visit Projects & Pursuits for outreach details.

Volunteer Registration Form

*All fields marked with an asterisk are required. Please write N/A if it does not apply to you.

Medical Specialty / Occupation*
Area of Focus. For example, if you are an acupuncturist or nurse, then that would be your area of focus.*
Current Place of Employment / Current University of College of Study*
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email*
Enter Email Confirm Email
Home Phone (daytime)*
Mobile Phone (evening)*
Whom May We Thank for Referring You?*
Referral Contact Email and/or Phone Number:
RESUME / CV: Please copy and paste your resume (and licensure information, if applicable) below. If there is not enough space, please send separately to theglobalclinic@gmail.com.*
Registration Fee: This form must be accompanied by a one-time, non-refundable $35 registration fee. Applicants will not be considered for outreach until this fee has been received in full. Payment information can be found under the page Donate Today.*
- I will submit the fee via PayPal
- I will submit the fee via a mailed check
Please Read Carefully: By signing below, I understand that I am submitting only the preliminary registration form at this time and will pay the non-refundable $35.00 fee that accompanies this form. If I am accepted, I agree to fill out a full application, including my medical history, emergency contacts, and various other forms.*
Signature/Date
A confirmation will be sent to the provided email address certifying your information has been properly received. If you do not receive this confirmation within 3 days, please contact theglobalclinic@gmail.com or resubmit the registration form.
Please press the submit button only once; it may take a few moments to process your application. Thank you for your interest!

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