Student Volunteer Registration Form

First Name *

Middle Name

Last Name *

Birth Date *

Email *

Phone Number *

Current Address

Street Address *

Street Address Line 2 *

City *

State / Province *

Postal / Zip Code *

Country *

Permanent Address (optional)

Street Address *

Street Address Line 2 *

City *

State / Province *

Postal / Zip Code *

Country *

Are you a U.S. citizen or a Permanent Resident?
Selecting "No" does not restrict ability to attend. *

Yes

No

Please specify

Do you currently hold a valid passport?

Emergency Contacts

First Name

Last Name

Relationship ex. Father, Mother, etc.

Phone Number Of Person To Contact In Case Of Emergency

First Name

Last Name

Relationship ex. Father, Mother, etc.

Phone Number Of Person To Contact In Case Of Emergency

Academic/ Professional Background

School of Attendance

Year Level

Other

Degree Level

Other

Program/ Major/ Minor

If other, please specify

Curriculum Vitae, Resume, or List of Achievement

Please list any certifications or professional trainings received

e.g. medical assisting, CPR certification. If none enter "N/A""

Please list any organization or professional memberships and/or notable achievements

e.g. Health & Educational Relief Organization (HERO) member 2018-Present. If none enter "N/A""

Please list any notable volunteer or community service experiences

e.g. Health & Educational Relief Organization (HERO); Medical mission trip volunteer 2017. If none enter "N/A""

Additional Information

Although not required, we would like to give you the opportunity to give us more insight into why you are applying for this mission. You may provide personal comments below. Your response may be as creative or traditional in form as you desire.

What is your confidence level in measuring and interpreting vital signs?

I can confidently measure and interpret vital signs including blood pressure and blood sugar WITHOUT guidance or supervision.

I can confidently measure and interpret vital signs including blood pressure and blood sugar WITH guidance or supervision.

I would like additional training in measuring and interpreting vital signs including blood sugar and blood pressure.

Other

What is your confidence level in performing patient intake and registration?

I can confidently register patients and assess patient needs including chief complaint and medical history WITHOUT guidance or supervision.

I can confidently register patients and assess patient needs including chief complaint and medical history WITH guidance or supervision.

I would like additional training in registering patients and assessing patient needs.

Other

Student teams regularly participate in a service project for patients as well as fundraise for items needed at clinic. Items needed may include labels for medications, sandwich bags for dispensing, multivitamins, pain medications such as Tylenol and other OTC items, soap, shampoo, toothbrushes, toothpaste, and other items. Are you willing and able to partake in and/or contribute to this year's service project? If so, please list ways you would be willing to contribute.

Yes, I am willing and able to work with my Team to contribute to this year's service project.

I can work with my Team Members to fundraise or donate funds to purchase items.

I can work with local businesses, health departments, or other entities to obtain needed items

Other

I understand HERO will make flight arrangements to and from Guyana for me at their discretion. I understand I am responsible for securing ground transportation to the designated airport to Guyana and from the designated airport upon arrival back to the United States

I understand and agree with the above statement.

Please list your prefered airport for Departure to Guyana on Saturday, 8/3/24 and Arrival to the United States on Saturday, 8/10/24.

T-Shirt Size (Unisex Cotton T-Shirt)

XS

Small

Medium

Large

XL

XXL

XXXL

Other