2022 Domestic Volunteer Scholarship Funding Application Question Title * 1. Please provide your contact information. Name Company/Institution/Hospital Address Address 2 City/Town State/Province ZIP/Postal Code Country Email Address Phone Number Question Title * 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. Question Title * 3. Are you board certified? Yes No Question Title * 4. Are you board eligible? Yes No Question Title * 5. Please select the option that best applies to you. I am a medical student. I am a resident. I am a fellow. I am a hand therapist in training. I am junior faculty (less than 3 years in practice). I am faculty (3 years or more in practice). I am a hand therapist in practice. Question Title * 6. If applicable, in what year did you complete your hand fellowship? Question Title * 7. Please select the option that best applies to you. I am an Orthopedic Surgeon or training in Orthopedic Surgery. I am a Plastic Surgeon or training in Plastic Surgery. I am a General Surgeon or training in General Surgery. I am a Hand Therapist or training in Hand Therapy. Other (please specify) Question Title * 8. Are you an AAHS member? Yes No I have applied for AAHS membership and agree to maintain my AAHS membership for at least 3 years. Question Title * 9. I am very competent to perform (select all that apply)... Basic hand surgery Burn surgery Pediatric hand surgery Elbow surgery Shoulder surgery Hand therapy procedures and techniques Other (please specify) Question Title * 10. Please indicate any secondary skills that you have that may be useful on a volunteer mission. Question Title * 11. Please indicate any previous volunteer work. 1. 2. 3. Question Title * 12. What languages do you speak, and are you fluent in these languages? 1. 2. 3. Question Title * 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)? Yes No Question Title * 14. Are you suffering from any communicable health condition that could impose any significant health and safety risk to patients? Yes No Question Title * 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? Yes No Question Title * 16. If you answered yes to any of the above, please describe your situation as appropriate. Question Title * 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. PDF, DOC, DOCX, GIF file types only. Choose File Choose File No file chosen Remove File 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. Question Title * 18. Please upload a letter of interest, including how volunteerism is important to your hand care practice. 500 word maximum PDF, DOC, DOCX file types only. Choose File Choose File No file chosen Remove File 500 word maximum Question Title * 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. PDF, DOC, DOCX file types only. Choose File Choose File No file chosen Remove File 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. Question Title * 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. PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only. Choose File Choose File No file chosen Remove File 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. Question Title * 21. Please upload a copy of your current CV. PDF, DOC, DOCX file types only. Choose File Choose File No file chosen Remove File Please upload a copy of your current CV. Question Title * 22. Please upload a copy of your medical license. PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only. Choose File Choose File No file chosen Remove File Please upload a copy of your medical license. Question Title * 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. Yes No Question Title * 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. Yes No Question Title * 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. Yes No Done