Your Specialty (required)
Choose One:Plastic SurgeonAnesthesiologistCRNAPediatricianOR NursePACU NurseNurse PractitionerDentistDental HygienistDental AssistantSpeech Pathologist

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

Prefix

First Name (required)

Last Name (required)

Suffix

Preferred Nickname

Applicant Address

Address 1 (required)

Address 2

City (required)

State (required)

Zip/Postal Code (required)

Country (required)

Home Phone

Cell Phone

Email Address (required)

Email 2 (if applicable)

Personal Information

Birth Date (required)

Gender Choose One:MaleFemaleUnspecified or another gender identity

Name on Passport

Passport Number

Passport Expiration

Nationality

Practice Information

Area of Specialty

Office or Hospital Name (if applicable)

Office or Hospital Phone

Travel Info and Trip Fees

Alliance for Smiles will cover international travel costs for medical volunteers, but if you are approved for a mission please consider making a tax-deductible donation to cover all or part of your airfare.

All mission volunteers are required to pay a $450 Mission Participation Contribution once they have been selected for a mission.

If you agree to above, please click Yes
YesNo

General Information

Do you speak any languages besides English? (Indicate level of fluency).
If you are applying from a non-English-speaking country, please indicate your level of fluency in English.

Prior Medical Missions You Have Gone On (if any)

Are You A Member of Rotary? (Indicate club name/district and how long.)

Do you have any medical conditions we should be aware of?

Shirt Size (in unisex size)
Choose One:XSSMLXLXXLXXXLOther

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

Full Name of Reference

Title

Phone

Email

Notes

Reference Two

Full Name of Reference

Title

Phone

Email

Notes

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: Attestation Form

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 on the contact page.

To upload the documentation now, please upload below.
Accepted formats: .doc, .docx, .pdf, .jpg, .zip, .png, .gif. Size limit 10 MB.

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.

If approved for a mission we request you provide us with 25-50 names and/or email or mailing addresses of family and friends, to be collected for our fundraising database.

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.

Do you agree to the above terms?
YesNo

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

• ~ Cover Letter and Resume (Please include how you heard about AfS, how you would like to volunteer for us, and your skills/qualifications.)

• - Photocopy of Passport

• 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

Prefix

First Name (required)

Last Name (required)

Suffix

Preferred Nickname

Applicant Address

Address 1 (required)

Address 2

City (required)

State (required)

Zip/Postal Code (required)

Country (required)

Home Phone

Cell Phone

Email Address (required)

Email 2 (if applicable)

Personal Information

Birth Date (required)

Gender
Choose One:MaleFemaleUnspecified or another gender identity

Name as Shown on Passport

Passport Number

Passport Expiration

Nationality

Travel Info and Trip Fees

Non-medical volunteers are required to pay their own airline expenses (unless a mission is funded by a specific grant). In addition, each volunteer is required to pay a tax-deductible $450 mission participation contribution once once they have been selected for a mission. AfS will cover the cost of food, lodging, and ground transportation for all volunteers during the mission.

If you agree to the above, please click Yes
YesNo

General Information

Do you speak any languages besides English? (Indicate level of fluency)

Prior Medical Missions You Have Gone On (if any)

Are You A Member of Rotary? (Indicate club name/district and how long.)

Do you have any medical conditions we should be aware of?

Shirt Size (in unisex size)
Choose One:XSSMLXLXXLXXXLOther

Professional References

Please list a professional or personal reference who we may contact if necessary.

Reference One

Full Name of Reference

Title

Phone

Email

Notes

Reference Two

Full Name of Reference

Title

Phone

Email

Notes

Documentation

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

• Cover Letter and Resume (Please include how you heard about AfS, how you would like to volunteer for us, and your skills/qualifications.)

• Photocopy of Passport

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. Mailing address and contact info are on the contact page.

To upload the documentation now, please click upload below.

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.

All volunteers must be vaccinated for COVID-19, and hepatitis A & B before participating in a mission.

If approved for a mission we request you provide us with 25-50 names and/or email or mailing addresses of family and friends, to be collected for our fundraising database.

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.

Do you agree to the above terms?
YesNo

In addition to this application, the below items should be submitted. (You can fill out the application now, and send these items later if you choose.)

• - Cover letter and resume - Please include your international and/or medical experience (if any)

• - Short video of yourself - Please tell us why you would be a great asset to our team and how you heard about AfS.

Applicant Name

First Name (required)

Last Name (required)

Suffix

Preferred Nickname

Applicant Address

Address 1 (required)

Address 2

City (required)

State (required)

Zip/Postal Code (required)

Country (required)

Home Phone

Cell Phone

Email Address (required)

Email 2 (if applicable)

Additional Information

Birth Date (required)

Gender as shown on travel document
Choose One:MaleFemaleUnspecified or another gender identity

Nationality

School Name (if applicable)

Current School Year (if applicable)

Do you speak any languages besides English? (Indicate level of fluency)

There will be times when you will be asked to wear an Alliance for Smiles t-shirt or polo shirt that will identify you as a team member.
Shirt Size (in unisex size)
Choose One:XSSMLXLXXLXXXLOther

Please describe your current health, including any medical conditions we should be aware of.

References

Personal Reference [non-family member; someone who has known you for at least 5 years]

Name

Title

Phone

Email

Notes

Professional Reference

Name

Title

Phone

Email

Notes

Documentation

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

• - Cover letter and resume - Please include your international and/or medical experience (if any)

• - Short video of yourself - Please tell us why you would be a great asset to our team and how you heard about AfS.

You can upload these items now at the below link, or you can submit the application now and upload these items later. (You will receive the below link in an email, once you hit SUBMIT below.)
Upload Documents Here: www.dropbox.com/request/vXRTqLbm7NIfQfVL1xKR

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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.
Do you agree to the above terms?
YesNo