Ophthalmologists

“To decrease the burden of blindness in the developing world through clinical care, teaching, and research.”

• General
• Ophthalmologists
• Others

VOLUNTEER APPLICATION FORM  Ophthalmologists Volunteer trips info

Name		E-mail
Address (home)		Address (work)
Phone (h)	(W)    Fax
Date of Birth		Name of spouse
	Check if applicable:
Are you a Resident ? Yes No Are you a fellow ? Yes No Please list your specality if any Cornea and External Disease Cataract and RefractiveSurgery Glaucoma Uveitis and Ocular Immunology Vitreoretinal Diseases. Ophthalmic Plastic Surgery. Pediatric Ophthalmology. Neuro-ophthalmology Ophthalmic Pathology
Medical / other School (or Training)
Place of Ophthalmic Training
Board Eligible? Certified?   other certification?
Are you an American Academy of Ophthalmology Member?
List certification / memberships in other professional ophthalmology organizations
Check All Surgeries That You are Qualified to Perform:
	PHACO / IOL ECCE / IOL PTERYGIUM REMOVAL TRABECULECTOMY WITH ANTISCARRING MEDICINE GLAUCOMA DRAINAGE IMPLANT SURGERY
Prior Overseas Experience (explain)
How did you hear about Christian Eye Ministry?
Are you bringing family / staff with you? (if so list)
Religious Preference / Denomination
Pastor’s Name		Phone
Address
Emergency Contact:
Name		Relationship
Address		Phone
Please supply 2 (two) Medical References:
Name		Phone
Address
Name		Phone
Address
Please describe what motivates you to apply for volunteer service with Christian Eye Ministry:
I recognize that I am making this trip voluntarily at my own expense and that CEM and the affiliated clinics are not liable for any accidents and/or mishaps, either traveling to or from or while working at a CEM clinic. However, CEM has pledged to support me in every way possible so that I will be able to function in a professional and effective manner to the best of my ability.