HEALTHCARE PROVIDER APPLICATION

Full Name

First Name

Last Name

Date

YYYY

Age

Email Address

Phone

(###)

###

####

If 'other,' please state your desired role

Street Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact Name

Your Relationship to Emergency-Contact Person

Law-Enforcement Record

Have you ever been convicted of any crime including either a felony or a misdemeanor? If yes, please describe when, where, and the nature of the charge (some types of offenses do not necessarily preclude service)

EMPLOYMENT INFORMATION: HEALTHCARE PROVIDERS

Current or Last Employer

Position Held

Employer's Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Name of Degree. License or Certification

State or Institution Issuing License or Certification

Date of Issue

Expiration date

Languages Spoken and/or Written

Please note your fluency with speaking/writing each language

Previous International or Cross-Cultural Medical/Relief Work or Volunteer Experience

P(please note the country, type of service, and the dates involved

Additional Skills You'd Like Us to Know About

This is optional, but it lets us know a little more about how you might help

The following is a disclaimer/release of liability. A signed copy is required before engaging in patient care and/or field work with Frontline.

GENERAL RELEASE/DISCLAIMER OF LIABILITY In consideration of Frontline Wellness United arranging a volunteer assignment for me, and with the intention of binding myself, my heirs, legal representatives, successors and assigns, I hereby expressly RELEASE AND FOREVER DISCHARGE Frontline Wellness United, its officers, directors, employees, volunteers, agents, legal representatives, insurers, successors, and assigns from any and all claims, demands, damages, liabilities, and causes of action that I now have or may in the future have, whether known or unknown, of whatsoever nature, relating to or arising out of my selection as a volunteer by, or my service as a volunteer with Frontline Wellness United. This includes, but is expressly not limited to, death, bodily injury, personal injury, property damage, loss or theft of property, economic loss, or any other damage, loss or cost. This document shall be construed according to the laws of the state or states in which service in association with Frontline Wellness United occurs. If a dispute should arise with respect to the meaning of any of the terms of this document, the rule of construction that a document is construed against the party preparing such document shall specifically not be applicable to the interpretation of this document. This General Release represents the entire agreement of the parties hereto and supersedes any and all prior or contemporaneous oral or written understandings, statements, representations or promises. All of the terms hereof are contractual and not mere recitals. I acknowledge that I have carefully read this General Release, know and understand the contents thereof, and that this document was freely and voluntarily executed. I acknowledge that I was given the opportunity to seek independent legal counsel on any and all matters herein before I signed this General Release/Disclaimer of Liability.

Please check this box to indicate that you've read the disclaimer/liability form.

I have read and understand the release/disclaimer of liability form.

Code of Conduct: Staff and Volunteers: In working with/volunteering for Frontline Wellness I agree to abide by the operating principles and procedures of the agency throughout the period of my assignment. I will treat all fellow volunteers, staff—and the persons and the communities we serve—with dignity and respect. I agree to conduct myself nonviolently in both speech and action during any period of time I am engaged in my duties as a Frontline Wellness United volunteer, or representing the agency in public or private. *

Please check here if you agree to abide by Frontline's Code of Conduct

I agree

How did you hear about Frontline?

Thank you for applying with Frontline. We'll contact you as soon as we've reviewed your application—typically within 48 hours of our having received it.

We look forward to talking with you.