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name (as it appears on passport) |
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address |
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state |
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zip code |
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phone |
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email |
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business |
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phone |
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fax |
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email |
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date of birth |
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beneficiary (required for insurance purposes) |
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| Special Interests and Skills |
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| What are your specific reasons and goals for volunteering? |
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| Do you have any specific public health or medical interest or skills which might be useful in developing countries? If so, please describe. |
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| Do you have any specific non health related interests or skills which might be useful? If so, please describe |
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| Availability: |
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| How long would you be available for work in our project areas? (The average stay is between two to eight weeks.) |
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| When would you be available to travel? Please list several alternatives in order of preference. |
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| Prior Overseas Experience |
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| Have you ever worked in a developing country? If so, please explain |
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| Do you speak Spanish? If so, please describe your degree of fluency and experience |
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| Professional Information |
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current job title |
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amount of time in this position |
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| Brief description of duties: |
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| IMPORTANT NOTE FOR MEDICAL VOLUNTEERS: A photocopy of all professional diplomas, licenses, and certificates is required in order to obtain proper authorization to work in our project sites. Please submit copies of all pertinent documents with this application. Failure to do so will delay the processing of your application. If you are currently a student, submit a letter from your school stating you are in good academic standing. |
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| Personal References: |
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name |
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address |
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zip code |
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phone |
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| Professional References: |
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name |
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address |
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state |
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| Health Status |
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| Do you have any significant health problems? If so, please describe |
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| Do you have any dietary restrictions? |
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| Do you have any allergies? |
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| Person to be notified in the case of an emergency |
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name |
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address |
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city |
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state |
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relationship |
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| My application to Curamericas Global, Inc. for short-term volunteer work in Latin America is being submitted with the following understandings: |
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- I will be a guest in the local country and subject to the laws and customs of the native society and to the policies of Curamericas Global;
- I will be working under and subject to the authority of the local Curamericas Global Project Director; I agree to abide by his/her directives and recommendations while visiting and working in Latin America;
- I will be responsible for obtaining the funds needed to cover my transportation expenses, lodging, meals and an interpreter (if needed) and any other expenses incidental to my stay; and
- I understand that there are personal health and safety risks involved in this type of endeavor for which Curamericas Global is not responsible.
- Photo Consent Release: I give my consent for Curamericas Global's use of photographs or videotapes of me while participating in volunteer activities. These photographs or videotapes may be published in newsletters, the website or brochures.
Please send any attachments by email to info@curamericas.org or mail to the following:
Curamericas Global, Inc.
2245 North Hills Drive, Suite E
Raleigh, NC 27612
1-877-510-4787
1-866-510-8611 (fax)
By clicking submit, I acknowledge and agree to the above terms.
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