Volunteer Application

ISM Volunteer Application

Contact Information

Name*
	First	Middle	Last
Indicate name exactly* as on passport

Address
	Street

	City	State	Zip

Phone
	Primary xxx-xxx-xxxx	Secondary xxx-xxx-xxxx

Email		DOB
			(mm-dd-yyyy)

Emergency Contact Information

Name
	First	Last
Phone
	Primary xxx-xxx-xxxx	Secondary xxx-xxx-xxxx

Professional Experience

	Professional Role
	Fluent foreign languages?
	Professional License/ Certification Number
	Passport Number	Expiration Date (mm-dd-yyyy)

RELEASE I, in consideration of participation as a paid or volunteer staff person to International Surgical Mission (hereinafter, "ISM" to include its board members, officers, management, agents, employees, successors and assigns), agree to the following: 1. Travel overseas and to foreign countries and residing therein, is inherently dangerous and may be risky. ISM has no control over entities, events, or persons who may reside there. Such risks include but are not limited to accidents, acts of war, terrorism, illnesses, crime, floods, earthquakes, political instability, and the like. This list is meant to be illustrative and not all inclusive. 2. I, hereby release, and hold harmless ISM, its board members, officers, management, agents, employees, successors, and assigns for any and all injuries, loss of life, damage to property to myself or my family, which occur related to or arising from traveling or residing, performing at or enroute to an ISM position overseas or in the United States. 3. I, hereby release and hold harmless ISM from any and all claims, lawsuits, damages, and the like arising from said activity described in the foregoing paragraph. 4. I, wholly accept responsibility and liability for all risks and perils related to my position and travel for ISM. If a matter arises under this RELEASE, the place for jurisdiction shall be Pueblo County, Colorado, US. I have read and understood the terms of this RELEASE and accept it knowingly and willing.

I have read and accept the above release.

If you are interested in a specific trip (s), e-mail us at: international_surgical_missions@yahoo.com
and tell us of your interest