Registration – Medical

REGISTRATION – MEDICAL

This form is for Medical Volunteers. There is another form for Nonmedical Volunteers.

Step 1 of 4

Prepare the following documents in legible PDF format before you proceed.

⇀ ID Photo (in JPG format)
⇀ Passport
⇀ CV in English
⇀ Highest Educational Certificate
⇀ Reference Letter
⇀ License (except Biomedical Engineers)
⇀ Speciality Diploma (except Biomedical Engineers & Nurses)
⇀ Board Certification (only for Anaesthetists, Paediatricians & Surgeons
⇀ PALS or equivalent (only for Anaesthetists, Nurses & Paediatricians
⇀ BLS or equivalent (only for Nurses)
⇀ Proof of previous credentialing, if applicable

PERSONAL PARTICULARS

Salutation

Name

First

Last

Preferred Name

How would you like us to address you?

Gender

Birth Date

Nationality

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Your primary email address.

Mobile

Please include country code with your number in the format +65 XXXXXXXX

Languages Spoken

WORK DETAILS

Organisation Name

If you are currently not working, write ‘NA’.

Organisation Website

Designation

Speciality

Do you still practice in your stated speciality?

Have your medical privileges ever been suspended?

Have you ever participated in any medical missions?

Have you been credentialed by other charities that provide cleft surgery?

REFEREE DETAILS

Your referee may or may not be your current supervisor but should be able to vouch for you at a professional level. Both of you should share the same speciality.

Referee Salutation

Referee Name

First

Last

Referee Email

Your referee’s primary email address.

Referee Mobile

Please include country code with your number in the format +65 XXXXXXXX

Organisation Name

If your referee is currently not working, write ‘NA’.

Referee Designation

Referee Speciality

Years Known

Indicate number of years your referee has known you for.

Relationship with Referee

In what capacity did you work with your referee?

Is your referee a Smile Asia volunteer or official?

Job Scope

Briefly describe the nature of your current work.