Overseas volunteer application form

Country in which you are volunteering:*

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Personal information
Title*
Name*
Last name Surname
As on your passport
Friendly name
If different from your passport name above
Date of birth*
Gender*
Email*
Mobile phone*
Daytime phone number*
Your address
Street Address line 2 City County Postcode Country

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Work information
Work email
Work phone number
May we phone you at work?
- Yes
- No

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Preferred contact email*
Preferred phone*

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Passport information
Passport number*
Nationality on passport*
Place of passport issue*
Date of passport expiry*

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Emergency contacts
1st emergency contact name*
First Last
1st emergency contact relation to you*
1st emergency contact email*
1st emergency contact number*

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2nd emergency contact name and telephone number
2nd emergency contact name*
First Last
2nd emergency contact relation to you*
2nd emergency contact email address*
2nd emergency contact number

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Your employment
Profession*
Please enter your GDC number or equivalent dental council registration number*
What year did you qualify in the dental profession*

YYYY only the year please (Not the day and month)
What company do you currently work for?*
What is your current position?*

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Skills
What are your particular skills and experience that you wish to offer to this project?*
What are your reasons for wanting to be involved in this voluntary work?*
Your previous voluntary experience (if any)*

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Professional reference
Please give the names and addresses of two people who will act as referees for you regarding your suitability as a volunteer. (These referees should not be a relative or your own doctor.)
Name of professional referee*
Position*
Company/organisation*
Contact number*
Email address*
How long has this person been acquainted with you?*

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Professional or personal referee
Should not be a family member
Second referee name*
Second referee position*
Second referee contact number*
Second referee email*
Second referee - how long has this person been acquainted with you?*

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Medical form
Please answer the following questions to cover the past 5 years. Failure to disclose important, relevant, medical conditions and associated medication, may result in the volunteer being excluded from the mission
1. Raised blood pressure*

Either n/a or please give details.
2. Heart or circulatory disease*

Either n/a or please give details.
3. Eplilepsy and/or fainting attacks*

Either n/a or please give details.
4. Mental health issues including depression or anxiety*

Either n/a or please give details.
5. Chest or lung disease*

Either n/a or please give details.
6. Vertigo*

Either n/a or please give details.
7.Diabetes*

Either n/a or please give details.
8. Joint or back injuries/problems*

Either n/a or please give details.
9.Allergies (hay fever, dietary, chemicals, drugs etc)*

Either n/a or please give details.
10.Asthma, bronchitis and/or shortness of breath*

Either n/a or please give details.
11. Digestive or bowel disorders*

Either n/a or please give details.
12.Cerebral disease (eg. stroke)*

Either n/a or please give details.
13.Fractures,tendon,ligament/cartilage damage)*

Either n/a or please give details.
14. Surgical operations*

Either n/a or please give details.
15. Haematological or blood disorders*

Either n/a or please give details.
16. Metabolic or endocrinal disorders*

Either n/a or please give details.
17. Pregnancy in last 2 years*

Either n/a or please give details.
18.Physical disability*

Either n/a or please give details.
19. Carrier of infectious diseases*

Either n/a or please give details.
20. Migraine*

Either n/a or please give details.
21. Hospitalised in last 2 years*

Either n/a or please give details.
22. Registered disabled*

Either n/a or please give details.
24. Any illnesses or conditions not already mentioned*

Either n/a or please give details.
25. Regular medication*

Either n/a or please give details.
Blood group*

If known
Have you been fully vaccinated against Covid-19?*

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Doctor's surgery name and address*

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Information to email to Dentaid (jasmine@dentaid.org)
In the email subject box, please state "Documents", followed by the country you have applied for and your name. ie. "Documents Uganda Joe Smith"
A copy of your current CV detailing your education, employment and relevant training history.*
- Yes I will
A copy of your GDC certificate or equivalent dental registration certificate*
- Yes I will
A copy of your dental qualification certificate*
- Yes I will
A copy of your current DBS enhanced disclosure certificate.*
- Yes I will
A copy of your passport*
- Yes I will

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Deposit
Deposit Payment of £300*
- Yes I will
An invoice will be forwarded to you upon receipt of your application. (Your place will not be secure until this invoice is paid)

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Dentaid Overseas Volunteer Agreement
Dentaid's Overseas Volunteer Agreement can be found here: https://dentaid.dns-systems.net/volunteer-agreement/
I have read and agree to Dentaid's Overseas Volunteer Agreement*

Please enter your full name.
Date of volunteer declaration*
DD slash MM slash YYYY
Data Protection

By agreeing to these terms and conditions volunteers give consent to the information they provide to Dentaid being made available to other parties as deemed necessary by Dentaid for the purposes of their trip. This can include but is not limited to the following:

• Dentaid UK staff and volunteers – to enable processing of your application, your pre-trip training and support, and in case of any medical emergency.

• In-country project partners to support the planning for each trip and to take into account the needs of volunteers e.g. diets, allergies & in case of any medical emergency

• Volunteers on the trip:
* The Team Leader. This will include sensitive personal data such as relevant medical history to ensure appropriate support is provided to volunteers during the trip.
* Other volunteers will receive the basic contact information to facilitate communication between participants, particularly before departure.

• Agents of and suppliers to Dentaid in the UK and at our project locations, such as travel agents and accommodation and subsistence providers.

• Medical professionals, as required, in the event of a volunteer needing medical care during my trip.

• Photos and videos of the volunteer team are routinely taken to promote the work of Dentaid in print, electronic and social media to advertise, support and promote our charitable work. In signing these terms and conditions the volunteer agrees to images being used in this way.

• Dentaid will always pay due regard to the volunteers right to privacy concerning their information and will handle all data with appropriate sensitivity. Confidential information

• As a volunteer, you have an obligation to protect confidential or personal information in relation to other volunteers or patients. If you have access to confidential information (including addresses, telephone numbers or medical information) of colleagues or patients you should never discuss or disclose such information to anyone other than the person/s authorised to receive it both during and after your involvement with the volunteer programme.
I agree my email address can be shared with the other team members for contact purposes*

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Gift Aid declaration
Gift Aid means charities get an extra 25p for every £1 donated.

Gift Aid is a scheme which allows charities to claim from HMRC, the basic rate of tax their donors have paid. Gift Aid increases the value of donations by 25%, so it means even more money goes to the causes you care about – and it won’t cost you extra.

Please help Dentaid by signing the Gift Aid declaration.

Please skip this section if you are a non-UK taxpayer or you do not wish Gift Aid to be claimed.
Gift Aid declaration (type your name here)

I am a UK taxpayer and understand that if I pay less Income Tax and/or Capital Gains Tax in the current tax year than the amount of Gift Aid claimed on all my donations it is my responsibility to pay any difference.
Date of Gift Aid agreement
DD slash MM slash YYYY
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