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GUATEMALA |
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[GUAMAP]
[How to Volunteer]
[Patients]
[General Program] |
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| Volunteer Application |
Please complete and return to the
Guatemala Acupuncture and Medical Aid Project (GUAMAP),
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| PERSONAL IDENTIFICATION | ||||
| Name (as written on passport) | ||||
| Resident Street Address | ||||
| City | State | Zip | E-mail address | |
| Home Phone ( ) | Work Phone ( ) | |||
| Male | Female | Date Of Birth | Race | Ethnic Group |
| Single | Married | Other | Status | |
| Person(s) for whom you are responsible by age |
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| PASSPORT / INFORMATION | ||
| Passport No. |
Expiration Date |
Where Issued |
| Country | Countries of Citizenship | |
| You need a passport valid for at least six months after your scheduled return to U.S.. Have at least two pages blank for visa stamps. | ||
| Emergency contact name Relationship to you |
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| Home Phone No. ( ) | Work Phone No. ( ) | |
| SKILLS |
| Spanish: Highly Fluent Fairly good command Passable None |
| Describe language experience |
| Other language(s) spoken |
| I have skills in the following health areas: Acupuncture Naturopathy Medical Science Nursing Midwifery Dentistry Other Healing Arts List Credentials |
| Currently certified by recognized professional Board(s)? Number of years in practice |
| Type(s) of Practice (clinic, hospital, etc) |
| Medical Training - Where Completed and With Whom? |
| Briefly Describe your Practice |
| Describe any teaching experience in your area of expertise relevant to the work of GUAMAP |
| What strengths do you bring to this work? |
| CULTURAL EXPERIENCE |
| Have you traveled, worked, or studied in Latin America (Mexico, Caribbean, Central / South America)? Yes No |
| Somewhere else? Yes No |
| Describe and give dates of experience |
| Briefly explain your interest in working with indigent populations of Guatemala, including indigenous peoples. |
| List any affiliation with an organization doing work in Central America |
| Would the organization help financially sponsor your volunteer work? Yes No Maybe |
| Other involvement in community social, political or religious activities? If so then please comment |
| HEALTH |
| Indicate if you have any health conditions that might affect your work in Guatemala including but not limited to: allergies, chronic conditions, physical or other disabilities, emotional or psychiatric |
| Yes No . If yes, please describe |
| List any current prescriptions / regularly taken medicine: |
| Are you on a special diet? Yes No If yes please indicate type |
| Are you in sufficient physical shape to live in rustic camping type conditions? Yes No |
| What stressful event(s) have you experienced? |
| REFERENCES | |||
| Name three references. One reference needs to be familiar with your work in your field, the others should address Cultural Experience and/or your personal traits which are helpful to working as a foreign volunteer. GUAMAP will send a reference form to references you name below: | |||
| Name Relation to you |
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| Street Address |
City | State | Zip Code |
| Phone No. | Best to contact at e-mail | ||
| Name Relation to you |
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| Street Address |
City | State | Zip Code |
| Phone No. | Best to contact at e-mail | ||
| Name Relation to you |
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| Street Address |
City | State | Zip Code |
| Phone No. | Best to contact at e-mail | ||
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READ THE FOLLOWING STATEMENT CAREFULLY, I hereby certify that I have carefully read the GUAMAP VOLUNTEER CRITERIA and completed the GUAMAP VOLUNTEER APPLICATION and am interested in participating in the work of GUAMAP with populations in need in Guatemala. I understand that selection for this work further requires an interview, verification of my references, and further orientation prior to travel and other such criteria. I am willing to supply copies of certified professional medical credentials if approved. I further certify that my answers to all the question on this application are true and complete to the best of my knowledge. Signature Date of signature |
[GUAMAP]
[How to Volunteer]
[Patients]
[General Program] |