Application Form

Sumbit form

Please complete this form to continue your registration to become a Healing Ambassador. Helping us Reaching Every Corner Of Vulnerable Communities In Africa And Asia..

Personal Information بياناتك الشخصية

First Name الاسم الأول *

Last Name الأسم الثاني *

Religion الديانة *

Your Detailed Address عنوانك الشخصي بالتفصيل *

City

State/Province

ZIP / Postal Code

Country

Phone (mobile) رقم المحمول الشخصي *

Phone (work) رقم المحمول للعمل

Phone (home) رقم التليفون المنزلي

Fax فاكس

Personal Email Address الإيميل الشخصي *

Professional Email Address الإيميل الخاص بالعمل *

Select Your Speciality التخصص الطبي *

Your Speciality التخصص الطبي

Languages Spoken *

Emergency Contacts (please list two)

How did you hear about Healing Ambassadors? كيف سمعت عنا ؟ *

Name 1 *

Phone 1 *

Address 1 *

Name 2 *

Phone 2 *

Address 2 *

Professional Information المعلومات المهنية

Current Position: الوظيفة الحالية *

Medical School of Graduation كلية التخرج *

Dates Attended سنة التخرج *

Residency Program فترة الامتياز *

Date Completed سنة الامتياز *

Program Director المشرف علي فترة الامتياز *

Fellowship Program برنامج الزمالة

Date Completed سنة الزمالة

Program Director المشرف علي برنامج الزمالة

Please describe any previous experience traveling/working in developing countries أوصف اي خبرة سابقة مع السفر الي اي بلد من البلاد النامية *

Work-Related References (please list two who can attest to your specific medical abilities and have worked with you in the last two years) اشخاص في العمل ممكن الرجوع لهم

Name 1 *

Phone 1 *

Email Address 1 *

Name 2 *

Phone 2 *

Email Address 2 *

Board Certified شهادة البورد

Specialty *

Where taken *

Date Completed *

Board Eligible

Specialty *

Where taken

Date Completed *

Current Medical License Number رقم ترخيص مزاولة المهنة *

State *

Date issued *

Current Experience (please indicate which types of patients/programs with which you have had experience in the last five years): خبرات سابقة في اي خدامات تطوعية *

Please describe any previous experience traveling/working in developing countries *

Please answer the following questions:

Are you now or have you ever been involved in any litigation, lawsuits, claims, or arbitration, or are you now involved in any threatened litigation or claim related to your professional activities? *YesNo

Have judgments or settlements been made against you in professional liability cases or are you involved in any pending litigation or denied liability insurance at standard rates? *YesNo

Have you ever been denied liability insurance? *YesNo

Has your membership or renewal thereof in any medical organization ever been revoked, suspended, diminished, or denied? *YesNo

Have your privileges in any hospital ever been suspended, diminished, revoked, denied or not renewed? Have you ever been charged with any crime other than minor traffic violations? *YesNo

Has your license in any jurisdiction ever been limited, suspended, or revoked? *YesNo

Have you ever been subject to any disciplinary proceeding or action by any employer, hospital, or other entity or institution with respect to your professional activities or behavior? *YesNo

Have you ever received treatment, voluntarily or involuntarily for alcoholism or drug abuse, mental illness or psychiatric problems? *YesNo

Do you have any current or past health problems or conditions that would impact or limit your ability to practice medicine in a developing country? *YesNo

If you answered yes to any questions, please provide a brief explanation: *

Please Upload the following items:

Copy of the Educational Certificates (Like Bachelor degree, Diploma, Master, PHD, etc.) *

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Copy of the most recent Medical License *

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Curriculum Vitae including explanation of any time gaps within the last five years *

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Copy of passport (Valid for 6 months at least) or ID *

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I certify that the information on this application is true to the best of my knowledge. I authorize all persons and institutions to disclose to and share with Healing Ambassador opinions and information regarding me, including but not limited to, information contained in this application and my skills, experience, fitness to practice medicine, character, work habits, and performance. I authorize Healing Ambassador to release information contained in this application or obtained by Healing Ambassador pursuant to the authorization contained in this paragraph to Healing Ambassador’s Board of Trustees, committee members and staff.

Purpose of Volunteering:

I understand that the purpose of my volunteering with “Healing Ambassadors” is to improve the health and well-being of individuals and communities in need by providing medical care, health education, and humanitarian support. Our volunteers play a critical role in delivering services, offering their expertise, and contributing to our mission to reduce health disparities.

Key activities include:

Providing Primary and Emergency Healthcare: Volunteers assist in clinics, hospitals, and mobile health units, offering essential medical services such as general consultations, vaccinations, maternal care, and emergency medical interventions.

Health Education and Awareness: Volunteers help educate local populations about disease prevention, nutrition, sanitation, and general health awareness to empower communities with the knowledge to improve their overall health outcomes.

Disaster Relief and Crisis Response: In the event of natural disasters, conflicts, or public health emergencies, volunteers provide immediate medical support, distribute essential supplies, and work alongside local healthcare providers to stabilize affected populations.

Supporting Long-Term Health Programs: Volunteers assist with ongoing programs aimed at addressing chronic health conditions such as malaria, tuberculosis, HIV/AIDS, and malnutrition, through both direct care and community outreach.

Building Local Healthcare Capacity: Volunteers may also participate in training local healthcare providers, supporting the development of local health infrastructures, and strengthening community-based health systems for sustainable improvement.

Through their contributions, volunteers help us work toward a healthier, more equitable world where everyone has access to the care they need.

I agree to contribute my time and efforts to support this initiative.

Volunteer's Responsibilities:

As a volunteer, I agree to:

Follow the guidelines and policies set by “Healing Ambassadors”

Act with professionalism, respect, and courtesy in all interactions with staff, other volunteers, and those served by the program.

Attend volunteer orientation (if required) and any relevant training.

Notify the organization in advance if I am unable to attend a scheduled shift or activity.

Commitment

I understand that my role as a volunteer is [part-time/full-time] and that my time commitment may vary based on the needs of the program. I agree to fulfill my volunteer duties for the agreed-upon period or until I am no longer able to continue, whichever comes first. I will provide adequate notice if I need to discontinue my volunteer work.

Health and Safety

I acknowledge that the activities in which I will participate as a volunteer may involve physical or mental challenges. I agree to “Healing Ambassadors” of any health concerns or conditions that might impact my ability to volunteer safely.

I understand that “Healing Ambassadors” will take reasonable precautions to ensure a safe environment but is not liable for accidents, injuries, or illnesses that occur during my volunteer work.

Confidentiality

I agree to maintain the confidentiality of any sensitive information or data I encounter as a volunteer. This includes respecting the privacy of individuals served by the organization, as well as any proprietary or confidential organizational information.

Consent to Use of Image and Likeness

I grant permission to “Healing Ambassadors” to use any photographs, video, or other media taken during my volunteer activities for promotional purposes, in accordance with the organization’s policies. If I do not wish to be photographed or recorded, I will inform the organization.

Release of Liability

I understand and acknowledge that my participation in volunteering with “Healing Ambassadors” involves certain risks. I agree to release “Healing Ambassadors”, its employees, agents, and volunteers from any liability for injury, loss, or damage to my property or person that may occur as a result of my involvement in the volunteer activities, except in cases of gross negligence or willful misconduct by the organization.

Right to Terminate

I understand that “Healing Ambassadors” reserves the right to terminate my volunteer position at any time, with or without cause, if I fail to meet the organization’s expectations, policies, or code of conduct.

Acknowledgment and Consent

By Checking the consent box, I acknowledge that I have read and understand the terms outlined in this consent form. I voluntarily agree to participate as a volunteer for “Healing Ambassadors” under the conditions specified above.