Medical Volunteer Application

Please fill out our online application below.
Or download the PDF version here.

The following documents should be submitted with your application. You will have a chance to upload them at the end of the application, or you can submit them separately via email, fax or standard mail.

  • Current License to Practice
  • Curriculum Vitae
  • PALS Certification (for Pediatricians and PACU Nurses)
  • Diploma
  • Board Certification (for Surgeons, Anesthesiologists, CRNAs and Pediatricians)
  • Cover Letter (Surgeons: include cleft experience; Anesthesiologists: include pediatric experience; PACU Nurses: include pediatric experience)
  • Photocopy of Passport
  • Attestation Form - can be downloaded here: attestation form
  • Please Note: If you are selected to volunteer on a mission, we will need a headshot of you.  You may also submit that now.

 

Applicant Name
Title
First Name *
Last Name *
Suffix
Preferred/Nick Name
Applicant Address
Street 1
Street 2
City
State/Province
Zip/Postal Code
Country
Home Phone
Cell Phone
Personal Information
(Complete name as shown on passport)
Practice Information
Travel Info and Trip Fees

Alliance for Smiles will cover international travel costs for medical volunteers. Each volunteer is required provide their own transportation to and from the US point of exit (usually San Francisco or Atlanta).

Approved mission volunteers are required to pay a $380 Mission Participation Contribution once they have been selected for a mission.

General Information
(In unisex size)
Professional References
Please list two professional references - preferably physicians, dentist or allied health practitioners who are familiar with your work. If possible, include at least one member from the medical staff of each facility at which you have privileges.
Reference One
Reference Two
Documentation

The following documents must be submitted before you can be approved:

  • Current License to Practice
  • Curriculum Vitae
  • Diploma
  • Board Certification (only for Surgeons, Anesthesiologists, CRNAs and Pediatricians)
  • PALS Certification (only for Pediatricians and PACU Nurses)
  • Cover Letter (Surgeons: include cleft experience; Anesthesiologists: include pediatric experience; PACU Nurses: include pediatric experience)
  • Photocopy of Passport
  • Attestation Form - the form can be downloaded here: https://allianceforsmiles.org/files/pdf/attestation_form.pdf

If you don't have all the required documents currently with you, you can submit the application now and send the forms separately via email, fax or standard mail. (You will find mailing address/contact info on the next page after you hit Submit.)

To upload the documentation now, please use the button below.

Upload up to 7 files by clicking the Choose File button. (You can only upload one file at a time). You may also upload all documents together in one Zip file.

Once you have completed the application and uploaded all files that you wish to, please agree to the terms and hit the Submit button below.

I fully understand that any significant misstatement in or omissions from this application will constitute cause for denial of my application for affiliation with Alliance for Smiles. I hereby affirm that the information I have furnished to Alliance for Smiles on this application and in any accompanying document is true and complete to the best of my knowledge.