Dental Volunteering Application

Country in which you are volunteering*
Listed below are countries in which we still have vacancies

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Personal information
Title*
Name*
First Last
As on your passport
Friendly Name
If different from your passport name above
Date of birth*
Gender*
Personal Email*

Your personal email address
Mobile Telephone*
Dial Code - Number
Home Telephone*
Dial Code - Number
Your Address
Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

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Work information
Work Email
Work telephone number
May we telephone 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 names 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 education, employment and training history
Profession*
Please enter your GDC number*
What year did you qualify in the dental profession*
YYYY only the year please (Not the day and month)

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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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First 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 present employer*
Positon*
Practice name*
Employer Address*
Employer contact number*
Employer email address*
How long has this person been acquainted with you?*

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Second Reference
Second Reference name*
Second Reference Positon*
Second Reference Address*
Second Reference Contact Number*
Second Reference Email*
Second Reference - 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. Psychiatric or mental illness*
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.
23. Obesity*
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
Weight*
Height*

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Doctor's surgery name and address*

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Information to email to Dentaid (info@dentaid.org) or upload
In the email subject box, please place the country for your volunteering and your name i.e. UGANDA Your Name To upload information visit https://dentaid.org/overseas-upload-point/ The required password is Overseas
A copy of your current CV detailing your education, employment and relevant training history.*
- Yes I will
A copy of your GDC certificate*
- Yes I will
A copy of your 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
A copy of your indemnity insurance*
- 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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Clarification of understanding
Volunteer declaration. I declare that I have read, understood and agree to all of the above terms and conditions. All the information on this application form is correct and I will advise Dentaid of any changes. I am not aware of any reason that would prevent me from taking part in this trip and I am fully committed to the dental mission for which I am applying. I understand that if I am accepted for this volunteering experience my deposit and all fundraising and donations are non-refundable.* https://dentaid.org/wp-content/uploads/2017/11/Dentaid-Volunteer-Terms-and-Conditions.pdf Data Protection Act: Dentaid is committed to ensuring that your privacy is protected. For the purpose of volunteering with Dentaid, we ask you to provide certain information by which you can be identified. You can be assured that it will only be used in accordance with this privacy statement. The information you provide will be held in accordance with the Data Protection Act and will only used by Dentaid for your volunteering with Dentaid and will NOT be shared with any other organisation or individual unless specifically required to enable the donation to be collected. For the purpose of the Data Protection Act, the data processor is Dentaid Ltd, The Old Sawmills, Giles Lane, Landford, Salisbury. SP5 2BG. Please tick the following box and fill in the date to give your agreement for Dentaid to keep you updated with our charitable work both in the UK and abroad.
Volunteer declaration.*
Please enter your full name
Date of volunteer declaration*
Date Format: DD slash MM slash YYYY
Data Protection Act - permission*
Please enter your full nane
Date of Data Protection agreement*
Date Format: DD slash MM slash YYYY
I agree my email address can be shared with other team members for contact purposes*

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Gift Aid declaration
Please help Dentaid by signing the Gift Aid declaration
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
Date Format: DD slash MM slash YYYY

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Dental Volunteering Application

Overseas Application

Step 1 of 18

Personal information

Work information

Passport information

Emergency contacts

2nd emergency contact names and telephone number

Your education, employment and training history

Skills

First Reference

Second Reference

Medical form

Information to email to Dentaid (info@dentaid.org) or upload

Deposit

Clarification of understanding

Gift Aid declaration