Overseas volunteer application form

Country in which you are volunteering:*
Are you a member of the Dentaid Community Facebook group?
- Yes
- No

Personal information
Title*
Name*
First 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
How did you hear about the overseas trip?*
- Social media
- A dental show / conference
- Website
- Word of mouth
- News article
- Volunteered before
- Other

Passport information
Passport number*
Nationality on passport*
Place of passport issue*
Date of passport expiry*
MM slash DD slash YYYY

Emergency contacts
1st emergency contact name*
First Last
1st emergency contact relation to you*
1st emergency contact email*
1st emergency contact number*
Second emergency contact
2nd emergency contact name*
First Last
2nd emergency contact relation to you*
2nd emergency contact email address*
2nd emergency contact number

Skills and previous experience
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)*

Current 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?*

Professional references
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 1*
Position*
Company/organisation*
Contact number*
Email address*
How long has this person been acquainted with you?*
Second professional reference
Name of second referee*
Second referee position*
Second referee contact number*
Second referee email*
Second referee - how long has this person been acquainted with you?*

About you
Do you understand that if your attitude or behavior is unsatisfactory you will be asked to leave?*
- Yes
- No
Do you have any special dietary requirements?*
If you would like to take part with friends or colleagues please put their names here*
What size Dentaid T-shirt do you require?*
- S
- M
- L
- XL

Medical history
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.
Do you experience: Raised blood pressure*
If Yes please give details
Do you experience: Heart or circulatory disease*
If Yes please give details
Do you experience: Eplilepsy and/or fainting attacks*
If Yes please give details
Do you experience: Diabetes*
If Yes please give details
Do you experience: Allergies (hay fever, dietary, chemical, medication etc,)*
If Yes please give details
Do you experience: Asthma, bronchitis and/or shortness of breath*
If Yes please give details
Do you experience: Haematological or blood disorders*
If Yes please give details
Do you experience: Migranes*
If Yes please give details
Do you have a physical disability*
If Yes please give details
Are you a carrier of an infectious disease*
If Yes please give details
Do you take any regular medication*
If Yes please give details
Please disclose and illnesses or conditions not already mentioned*
Blood group*
If known
Please provide your doctor's surgery name and address*

Can you email the following to sarah.drew@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

Deposit declaration
Are you able to pay a deposit 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)
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

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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