February 2, 2021 C.U.R.E. Clinics Participant Application 1 Personal Information2 International Travel Experience & Expectations3 Agreement Select Trip*First ChoiceSecond ChoiceThird ChoiceVolunteer Type*MedicalNon-MedicalWhat is your degree acronym and specialty?*Do you have an area or areas of expertise as it relates to attending a C.U.R.E. Clinic?*Name* Mr.Mrs.MissMs.Dr.None Prefix First Middle Last Preferred first name if different from first name provided above:Email* Phone* Are you a returning Project C.U.R.E. international travel participant?*YesNoPlease list the Project C.U.R.E. international trip(s) that you have previously participated in.*Please tell us about your international travel experience, if applicable.Please list countries and purpose of travel.Please indicate language skills and proficiency level:*Please explain your reasons for wanting to participate in Project C.U.R.E.'s travel program.*Include any skills, training, certifications, or qualifications you will bring to the trip, as well as what you expect to take away from this experience. Each volunteer is expected to function as a team member and adapt to unexpected circumstances. Please give at least one example of your ability to work as a member of a team and how you were able to adapt to a changing environment.*International trips can be both emotionally and physically challenging. Are you able to cope with such challenges?*YesNo Agreement* I CERTIFY that all statements and information furnished in this Statement are true, complete and correct to the best of my knowledge and belief and are made in good faith. I understand that any information furnished on this form is subject to verification, and I agree to furnish supporting documents or information upon request and/or names, addresses and phone numbers (if known) of officials or other individuals who can substantiate the qualifications described above. I also understand that intentional misstatements or falsification will result in disqualification. Financial Agreement* I understand that my participant program fees are a non-refundable donation to Project C.U.R.E. Should I need to cancel my trip, I understand that I may use funds paid as a credit for future C.U.R.E. Clinics. How did you learn about C.U.R.E. Clinics?CommuniqueFriendNews MediaHospital/HospiceEmployerCommunity GroupReligious InstitutionEducation InstitutionSocial MediaInternetEmailUSA GovernmentOtherCAPTCHA
