Christian Eye Ministry Volunteer Application

Date:

Title:
*First Name:    *Last Name:   
Address (Home):
City:   State:   Zip:
Address (Work):
City:   State:    Zip:
Phone (h):    (w):    
*E-mail:     Fax: 
Date of Birth:    Name of spouse:

* Required Fields

Check if applicable:

Ophthalmologist:  
Sub-Specialty (specify):

 Resident:    Optometrist:     Nurse:    OR tech:

Ophthalmic tech:     Biomed Technician:

Other:    (specify):

 Medical / other School (or Training):

 Place of Ophthalmic Training:

 Board Eligible?    Board Certified? other certification?

 Are you an American Academy of Ophthalmology Member?  Yes    No

 List certification / memberships in other professional ophthalmology organizations:

  

 

Prior Overseas Experience (explain):

 How did you hear about Christian Eye Ministry?

 Are you bringing family / staff with you?    Yes    No        (if so list):

  

  

Religious Preference / Denomination:

 Pastor’s Name:    Phone:

 Address:

  

 

Emergency Contact:

Name:    Relationship:
Address:                                              Phone:

Please supply 2 (two) Professional References pertaining to your medical experience:

Name:
Address:                       Phone:

Name:
Address:                        Phone:

  

 

 Please describe what motivates you to apply for volunteer service with Christian Eye Ministry:

 

I recognize that I am making this trip voluntarily at my own expense and that CEM and the affiliated clinics are not liable for any accidents and/or mishaps, either traveling to or from or while working at a CEM clinic. However, CEM has pledged to support me in every way possible so that I will be able to function in a professional and effective manner to the best of my ability.

 

                     

 

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