New Medical Missions - Volunteer Information Form

New Medical Mission Volunteer Form

Thank you for your interest in contributing your professional expertise to our medical missions in Palestine. Kindly take a few moments to complete the form below, which will help us assess your qualifications, preferences, and availability. We also ask that you have your CV, professional license, and passport photo page ready for upload at the end of the form.
Personal Information
Full Name:*

First NameLast Name
Phone/Whatsapp number
Please enter a valid phone number.
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Your Professional Credentials (MD, DO, RN, NP, PA, DDS, etc)*
Your professional specialty *
Select the one that best describes your role while on this Mission.
If selected Other please specify specialty:
Have you volunteered on a mission to Palestine before?

yesno
Pediatric/Adult/Both:*
Start Date*

MonthDayYear
Start of Medical Mission
Departure City:
Frequent flyer number (if available):
Global Entry Number (if available):
Are you in good health and physically capable of performing the duties required during a medical mission with long hours and under stressful conditions?
Are you in good mental health and mentally capable of performing the duties required during the mission?
Please Provide Your Emergency Contact Information:
Emergency Contact - Full Name*

First NameLast Name
Relationship*
Phone Number*
Please enter a valid phone number.
Email Address
example@example.com
Please Upload Copy of your Passport Photo Page Here:*

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Please Upload Copy of your Professional License Here:*

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Please Upload Your CV Here:*

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By signing this form, I authorize HEAL Palestine to use the information on this form as needed to determine my eligibility for medical missions with HEAL Palestine. I also authorize HEAL Palestine to conduct any required background checks.

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New Medical Mission Volunteer Form

Personal Information

Please Provide Your Emergency Contact Information: