FTC Volunteer Resources

Medical Professional Volunteer Application

Thank you for your interest in volunteering for an FTC Medical Professional position. We will make every effort to process your application as soon as possible. If you meet the initial qualifications required for a FTC Medical Professional team member, we will contact you via e-mail with links to additional forms required for team membership.

We appreciate all offers to help, but FTC needs licensed/certified facial surgical specialists, anesthesiologists/anesthetists, and physicians established in their practices. We also need peri-operative nurses and technologists who have at least five years of experience.

We currently are unable to assign nursing, dental, and medical students and medical/surgical residents. We have provided other possible contacts for your search in the Resources Section of this website. Click on "Physician & Allied Health Services Opportunities Abroad" for your review.

We are unable to accommodate applicants who are in medical schools or residencies and seek only those who have completed their training with at least two years' experience.

Please fill out the form completely (the required fields are in bold). When finished, click the Submit button at the end of this form.

Thank you again for your interest in volunteering!

First Name:
Middle Name:
Last Name:
Preferred Name/Nickname:
Organization:
Address:
City:
State/Province:
Zip/Postal Code:
Country:
Work Phone:
Home Phone:
Fax:
Email:
Pager:
Cell:
Alternate Phone:
Alternate Phone Description:
Most team building and travel planning communications will be through the internet
Gender:	Male Female
Birth date:
Birth place:
Marital status:	Married Single
Spouse's name:
Number/ Name(s)/Age(s) of Children (or N/A):
Emergency contact (other than your spouse/home address):
Name:
Phone:
Address:
City:
State/Province:
Zip/Postal Code:
Country:
FTC provides travel/medical evacuation insurance for all team members through Travel Guard (www.travelguard.com).
I am professionally trained in the following areas:
oral-maxillofacial surgery craniofacial surgery facial plastic surgery oculoplastic surgery anesthesiology pediatrics nurse anesthetist (CRNA) peri-operative nursing surgical technology emergency medical technology physician assisting pharmacy nutritional support lactation/feeding techniques play therapy other
Education (School(s)/Year(s) Attended/Degree(s) Obtained):
Professional License #(s):
State(s):
Certification(s) (e.g. CPR, ACLS, ATLS, PALs, CCRN,CNOR.):
Work Experience:
Travel/Cross-Cultural Experience:
Passport #:
Issue Date:
Expiration Date:
Passport Authority Agency:
Have you gone on other surgical outreach trips? If yes, where did you go, what did you do, with whom, what did you learn/gain?
Other travel/cross-cultural experiences, in general:
Foreign language abilities:
Regional/country site preferences for future FTC trips and why:
Goals/Motivation What are your goals for this trip?
Personal Information Please give three adjectives that best describe your personality ( *Please refer to our Resources Section: Team Member Personality Indicator to select your MBTI Temperanemt (NF, NT, SP, SJ)/Temperament Adjectives*)
Please give three adverbs describing how you "Face the Challenge(s)":
Other pertinent personal information you want to share:
Spiritual Background:
Spiritual Orientation:
Denomination/Worship Body Preference:
Best Airport(s) from which to depart/to which to return:
Travel Schedule Preferences:
Men's Polo/Golf Shirt (100% cotton)
S M L XL XXL
Women's Polo/Golf Shirt (100% cotton)
S M L XL XXL
Surgical scrub top size
XS S M L XL
Surgical scrub bottom size
XS S M L XL
Upcoming Face the Challenge Team Surgical Trips If future FTC trips were done on a semi-annual basis and were 12-14 days long, what would be your travel date preferences and your availability? Please indicate your choices, numbering them in order of your preference (1-most preferred, 2-next preference, 3-third choice):
Vietnam - March/April 2010:	FULL
Trip Preparation Assistance How do you think you can help FTC before or during trips?
Teach through doing surgery Give a lecture Do pre-/post-op teaching Autoclave supplies Pack supplies Team support/building Prayer support Teach regional demographics Press releases Language translation Public speaking (churches, corporations, foundations, schools, etc.) Other
Procure supplies through personal contacts--Please specify:
Amenities (candy bars, healthy snacks, caf./decaf. coffee/tea) Anesthesia supplies (gases, masks, tubing, C02 monitors, etc.) Business supplies (charts, paper, labels, marking pens, etc.) Instruments (bone plating systems, cleft palate sets, etc.) IVs (Jelcos/Butterflies, sets, drip chambers, tubing, fluids, etc.) Luggage ([all wheeled] duffels, hard-shell suitcases, trunks) Medications (analgesics, antibiotics, antiemetics, induction meds) Monitors (all peri-operative types) Packing materials (bubble wrap, foam, small containers, tape) Surgical supplies (gauze, tape, Surgicel, Medpore, dressings, etc.)
Names/addresses/phone numbers of any people or companies you recommend FTC contact regarding supplies procurement:
Funding Information FTC is a 501 (c)(3) non-profit organization, tax ID # 84-125-1098, recognized by the IRS. All monetary gifts are tax-deductible and will be receipted to the donors.
If given the appropriate materials (e.g. brochures, etc.) in advance of your trip, would you be able to seek funds from your contacts (family, friends, churches, community organizations, educational institutions, foundations, etc.) to raise your own support for your travel expenses?
yes no
# of brochures/letters needed
Names/addresses/phone numbers of anyone or any foundations you would like FTC to contact to seek financial support for the organization in general
Do you believe you will need financial assistance to fund your trip?
yes no
How much do you project you might need?
Average cost per trip is between $3,000-$3,500 per team member, as determined by FTC, and is due 30 days prior to departure.

FTC is a 501 (c)(3) non-profit organization, tax ID # 84-125-1098, recognized by the IRS. All monetary gifts are tax-deductible and will be receipted to the donors.