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* 1. Please provide your contact information. 

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* 2. Please indicate the mission location and date(s) for which you are requesting HSE funding. If this mission is being facilitated by an organization, please indicate this organization and a direct contact within your response. 

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* 3. Are you board certified?

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* 4. Are you board eligible?

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* 5. Please select the option that best applies to you.

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* 6. If applicable, in what year did you complete your hand fellowship?

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* 7. Please select the option that best applies to you.

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* 8. Are you an AAHS member?

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* 9. I am very competent to perform (select all that apply)...

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* 10. Please indicate any secondary skills that you have that may be useful on a volunteer mission. 

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* 11. Please indicate any previous volunteer work.

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* 12. What languages do you speak, and are you fluent in these languages?

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* 13. Do you have any physical or mental disability that impairs or could impair your ability to carry out your professional obligations (please consider all types of physical or mental disability, including past or present substance abuse)?

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* 14. Are you suffering from any communicable health condition that could impose any significant health and safety risk to patients?

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* 15. In the past five years, including the present, have you had a history of chemical dependency or substance abuse that might adversely affect your ability to competently and safely perform medical services?

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* 16. If you answered yes to any of the above, please describe your situation as appropriate. 

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* 17. Please upload a detailed budget which outlines expenses for this trip. Be specific with each line item. Your budget should include travel, housing/lodging, supplies/equipment, other expenses as applicable.  

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* 18. Please upload a letter of interest, including how volunteerism is important to your hand care practice.

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* 19. Please upload a letter of support from an AAHS member or, if applicable, your Program Director confirming they are allowing you to travel and that you are in good standing. 

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* 20. Please upload a brief statement of support from the mission site that they would like you to come to volunteer, who will organize this mission, who will serve in a supervisor role.

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* 21. Please upload a copy of your current CV. 

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* 22. Please upload a copy of your medical license. 

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* 23. I agree to comply with the most current CDC, country, state, and local based COVID-19 safety policies in place at the time of my mission should I be selected for funding.

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* 24. Should you be selected for HSE funding, your participation in a mission is voluntary. You acknowledge the risks and complications associated with travel to and from, as well as participation and/or attendance  and herby release, waive, and forever, discharge any and all liability, claims, and demands of whatever kind of nature against AAHS, HSE, the AAHS and HSE leadership and officers, AAHS and HSE staff team and management, and AAHS and HSE partners and industry supporters, hereinafter the “Released Parties.”

By participating in a volunteer mission, I give full release of liability to the Released Parties to the fullest extent permitted by law.

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* 25. I certify that the above information is accurate, true and complete to the best of my knowledge, and that this information may be used to determine my eligibility to volunteer for a medical mission.

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