Bethany's Angels

"A Better Future Through A Healthier Childhood"

Volunteer Application

Please note: volunteers who are not medical professionals serve Bethany’s Angels in many valuable support roles. However it is necessary to fill all expedition openings first with trained medical professionals. Therefore, all students or non-medical trained applicants for field operations are required to recruit an MD, PA or equivalent to accompany them. Details on specific mission needs and specialties can be obtained by contacting the foundation’s director at Randy.Salo@BethanysAngels.com.
This requirement does not eliminate non-medical applicants who are unable to recruit from applying. Please do so as we wish not to turn anyone away. Our primary objective is to fill the ship’s muster list with medical professionals first.

Request for Information

Nme (full legal)(required)
Date of Birth
Street Address (line 1)
Street Address (line 2)
City
State
ZIP (Postal Code)
Home Phone
Work Phone
Cell Phone
e-Mail(valid email required)

Professional Background

Profession / Specialty (EIS)
Certificate / License #'s
Have your professional privileges ever been suspended/revoked?
Yes
No
If Yes please explain
Type of Volunteer service(s) you offer
Languages Spoken

Passport Info

Passport #
Place Passport Issued
Passport Expiration Date

Emergency Contact

Emergency Contact Name
Emergency Contact Relationship
Emergency Contact #1
Emergency Contact #2

Additional Information

How much notice do you need to join a mission team?
Have you immunizations for foreign travel as prescribed by the CDC?
Yes
No
Do you have any special dietary needs?
Yes
No
If so, please explain
Do you have any medical conditions we need to be aware of?
Yes
No
If so, please explain
Have you ever participated in overseas healthcare work?
Yes
No
If so, please explain
Why do you want to participate in our missions?
Why do you think you make a good volunteer?
How did you find out about Bethany’s Angels?

Release and Indemnification

By submitting this form I hereby release and indemnify Bethany’s Angels Foundation Inc., which is a non-profit corporation, and all it’s respective officers, directors, agents, contactors, employees, heirs, successors and assigns from prosecution or presentation of any claim for bodily injury or death or for property loss or damage incurred in connection with Bethany’s Angels Foundation, Inc., expeditions or related activities.
Please email or post mail, photocopies or scans of current licenses or certificates (if applicable), and a passport size photograph to: the addresses shown below this form
.cc a copy of this form to yourself
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cforms contact form by delicious:days

Randy.Salo@BethanysAngels.com

Or:

Bethany’s Angels Foundation, Inc.
13210 N. 72^nd Place
Scottsdale, AZ 85260

Thank you for your interest and good luck!