Dental Volunteering Application

Country in which you are volunteering*
Listed below are countries in which we still have vacancies (take note 2021 dates may be subject to change)

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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 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*
Positon*
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 Reference name*
Second Reference Positon*
Second Reference contact number*
Second Reference email*
Second Reference - How long has this person been acquainted with you?*
This reference is for BUPA applicants only
This reference needs to be from you local Bupa clinical director
Bupa Clinical Director name
Bupa Clinical Director Positon
Bupa Clinical Director contact number
Bupa Clinical Director email
Bupa Clinical Director - 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.
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)
In the email subject box, please place the country for your volunteering and your name i.e. UGANDA Your Name
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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Terms and Conditions
Full terms and conditions can be found here:-
http://tiny.cc/DentaidTandCs
I have read and agree Dentaid's terms and conditions for overseas volunteers*
Please enter your full name. Full terms and conditions can be found here:- https://www.dentaid.org/wp-content/uploads/2019/10/DENTAID-OVERSEAS-VOLUNTEER-TERMS-CONDITIONS-24.10.19-v4.pdf
Date of volunteer declaration*
Date Format: 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
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 employment

Skills

Professional Reference

Professional or personal referee

This reference is for BUPA applicants only

Medical form

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

Deposit

Terms and Conditions

Data Protection

Gift Aid declaration