Medical Volunteers

14%

Medical Volunteer Application

Required Documents

Board-Certified: Board Certification, Curriculum Vitae, Fellowship Certificate (if applicable), Medical Diploma, Medical License(s), Passport Bio Page, Residency Certificate, Statement of Understanding

Residents/Fellows: Curriculum Vitae, Medical Diploma, Passport Bio Page, Residency Certificate (if applicable) or Experience Report, Statement for Understanding

Nurses/Technicians: Curriculum Vitae, License/Certification, Passport Bio Page, Statement for Understanding
Please submit copies of the documents listed above with your application(Required)
Drop files here or
Select files
Max. file size: 50 MB.

Applicant Details

First Name(Required) Middle Name Last Name(Required) Suffix Home Address(Required) City(Required) State(Required) Zip / Postal Code(Required) Country(Required) Email(Required)

Home PhoneMobile(Required)

Business Information

Business Name Website Business Address City State Zip / Postal Code Country Business Email

Business PhoneFax

Additional Information

Languages Spoken(Required)

Medical License Information

License Number State Expiration Date

MM slash DD slash YYYY

License Number State Date

MM slash DD slash YYYY

Emergency Contact Information

Emergency Contact 1 First Name(Required) Emergency Contact 1 Last Name(Required) Emergency Contact 1 Phone Number(Required) Emergency Contact 2 First Name(Required) Emergency Contact 2 Last Name(Required) Emergency Contact 2 Phone Number(Required)

Release Waiver & Statement of Understanding

I (      ) release SEE International, its officers, clinic trip leaders, members, and team associates from responsibility for any accident, injury, sickness, or death to me or any member of my family and/or loss of material items occurring as a result of any clinic trip. I understand and accept the personal health and safety risks involved. I further authorize SEE International, its officers, team leaders, and other designated personnel to release any pictures or stories about my participation in a SEE short-term program to any news, radio, television, or other media. I have read, understood, and agree to the conditions of this waiver.Digital Signature(Required) Today’s Date(Required)

MM slash DD slash YYYY
As a SEE Volunteer, I understand that SEE was established as a humanitarian organization for the purpose of providing eye surgeries to people throughout the world, who are financially incapable of paying for medical services. I understand that I will be responsible for transporting supplies to the clinic site. I also understand that no supplies may be left behind; any unused supplies must be returned to SEE following the clinic. In the spirit of SEE’s fundamental principle of assisting the underserved, I will make certain that patients are NOT asked to pay for the following:

•The services of the Ophthalmology team

•The use of the equipment provided by SEE, including temporary and extended loaned

•All supplies and medications provided by SEE

I will be a guest of the host country and subject to the local laws and customs, as well as the policies of SEE International. I will be working under and subject to the authority of the host Ophthalmologist and hospital/clinic, and I agree to abide by his/her directives while visiting and working in the host country. I will be responsible for obtaining the funds needed to cover my transportation expenses, lodging, meals, and any other expenses incidental to my stay. I will be responsible for identifying and obtaining any and all necessary visas and other permissions, as well as any vaccinations prior to my departure. I understand that should it be necessary for me to cancel my participation, any refunds of airfare, or other prepaid services will be strictly my responsibility. I have read and understand this document and will uphold the principles and policies of SEE to the best of my abilities.
Digital Signature(Required) If this policy is not adhered to, SEE’s relationship with the companies that donate pharmaceutical and medical supplies will be in jeopardy and we will not be able to support you in your humanitarian endeavors. We cannot send supplies or support packages until the volunteers participating in the surgeries have signed this document and returned it to us by fax, e-mail, or regular US mail.Today’s Date(Required)

MM slash DD slash YYYY
As a SEE Volunteer, I understand that SEE was established as a humanitarian organization for the purpose of providing eye surgeries to people throughout the world, who are financially incapable of paying for medical services. I understand that I will be responsible for transporting supplies to the clinic site. In the case that there are unused supplies, I agree to abide by SEE’s policies regarding their disposition. In the spirit of SEE’s fundamental principle of assisting the underserved, I will make certain that patients are NOT asked to pay for the following:

•The services of the Ophthalmology team

•The use of the equipment provided by SEE, including temporary and extended loaned

•All supplies and medications provided by SEE

I acknowledge that third-year residents and those in their fellowship year may perform surgery during a SEE clinic only:

(1) under the direct supervision of their clinical professor; or,

(2) under the direct supervision of a board-certified ophthalmologist, after prior review and approval by SEE’s Programs Department and Chief Medical Officer.
In all cases, the in-country host ophthalmologist must agree to the third-year resident or fellow performing surgery before the start of the clinic. All other medical students and/or residents may only volunteer as assistants and under no circumstance can they perform surgery. I will be a guest of the host country and subject to the local laws and customs, as well as the policies of SEE International. I will be working under and subject to the authority of the host Ophthalmologist and hospital/clinic, and I agree to abide by his/her directives while visiting and working in the host country. I will be responsible for obtaining the funds needed to cover my transportation expenses, lodging, meals, and any other expenses incidental to my stay. I will be responsible for identifying and obtaining any and all necessary visas and other permissions, as well as any vaccinations prior to my departure. I understand that should it be necessary for me to cancel my participation, any refunds of airfare, or other prepaid services will be strictly my responsibility. I have read and understand this document and will uphold the principles and policies of SEE to the best of my abilities.
Digital Signature(Required) If this policy is not adhered to, SEE’s relationship with the companies that donate pharmaceutical and medical supplies will be in jeopardy and we will not be able to support you in your humanitarian endeavors. We cannot send supplies or support packages until the volunteers participating in the surgeries have signed this document and returned it to us by fax, e-mail, or regular US mail.Today’s Date(Required)

MM slash DD slash YYYY

Δ