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USNS Comfort September 2018 Mission Interest Form
Thank you for your interest in serving abroad on this special mission with the USNS Comfort.
First Name
*
Last Name
Email Address
*
Country
*
Afghanistan
Albania
Algeria
Andorra
Angola
Antigua
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia
Bosnia Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Central African Rep
Chad
Chile
China
Colombia
Comoros
Congo
Congo (Democratic Rep)
Costa Rica
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland (Republic)
Israel
Italy
Ivory Coast
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea North
Korea South
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar, (Burma)
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Qatar
Romania
Russian Federation
Rwanda
St Kitts & Nevis
St Lucia
Saint Vincent & the Grenadines
Samoa
San Marino
Sao Tome & Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad & Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Yemen
Zambia
Zimbabwe
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Select Your Credentialed Area(s)
*
Medical Interpreter (Local/Int'l Medical Students)
Cleft Lip/Palate Surgeon
Women's Health Provider
Resident Physician
Pediatricians
Family Practitioner
Licensed Independent Practitioner
Physical Therapist
Psychologist
Nutritionist
Dentist
Pediatric Dentist
Dental Personnel
Dental Hygienist
Dental Assistant
Nurse
Family Nurse Practitioner
Other
Other
Current Professional Title
*
Current Place of Employment
*
Dates You Are Interested In Volunteering
*
Sept. 26 - Returning Oct. 16
Sept. 26 - Returning Nov. 8
Sept. 26 - Returning Dec. 8
Oct. 16 - Returning Nov. 8
Oct. 16 - Returning Dec. 8
Nov. 8 - Returning Dec 8
SPECIAL: Oct 20-24 only
Cell Number
*
Best Day and Time to Contact you [option 1]
*
Best Method To Contact You
*
Cell
Email
Either is fine
Best Day and Time to Contact you [option 2]
*
Best Method To Contact You
*
Cell
Email
Either is fine
Questions and Comments
Approved Candidates Begin Here
Address 1
*
City
*
State
*
Zip
*
Background Check
As you are aware, a required background check was ordered and completed to include with your credentials for this mission. Any charges for your backgroun check paid by World Hope International will need to be reimbursed by you by means of a donation to WHI. A separate email will share the specific costs paid on your behalf. Thank you for your cooperation in this matter. Please acknowledge that you have read this.
*
I agree
Emergency Contact Name
*
Emergency Contact Name
*
Emergency Contact Email
*
You have provided credentials supporting your role on the USNS Comfort. Please confirm that you have not falsified any credentials and that everything you submitted is factual.
*
I confirm that all credentials submitted are factual.
Please confirm that you are in fit shape and good health to fulfill your role on the USNS Comfort.
*
I confirm
All candidates approved to serve on the USNS Comfort have been asked to read and agree to the terms outlined in the US Navy's Memorandum of Understanding (MOU) delivered separately by email to you. You are expected to abide by each and every regulation outlined in the MOU.
*
I agree to abide by the rules outlined in the MOU
All candidates who will provide medical care must currently be covered by professional liability (medical malpractice) insurance and must also be covered for international humanitarian service. The United States must be named as an additional insured for the time period you serve on the USNS Comfort. Please email a copy of your coverage to gwenplauche@worldhope.org.
*
I agree to this condition
I, the undersigned, acknowledge that I have received the Child Protection Policy and Standards of World Hope International (emailed separately) and I understand and agree to the terms set forth in the said document and as briefly summarized above.
*
clear
For more information, please contact our Logistics Coordinator,
Gwen Plauche
.
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