Trip Registration Step 1 Step 2 Step 3 Step 4 Step 5 Step 6 Contact Information Salutation Mr Mrs Ms Miss Dr Prof A/Prof Other First Name* You should enter your legal name, therefore enter your first name as it appears on your passport or drivers licence. Last Name* You should enter your legal name, therefore enter your last name as it appears on your passport or drivers licence. Gender* Male Female Other Email* Postal Address* Suburb* State* Postcode* Country* Australia Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire, Sint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos Islands Colombia Comoros Congo, Democratic Republic of the Congo, Republic of the Cook Islands Costa Rica Croatia Cuba Curaçao Cyprus Czech Republic Côte d'Ivoire Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Eswatini (Swaziland) Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard and McDonald Islands Holy See Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Palestine, State of Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Réunion Saint Barthélemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia South Korea South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Islands Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu US Minor Outlying Islands Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Åland Islands Date of Birth* Mobile Phone Number* Alternate Phone Number* T-shirt Size* Women's Size 10 Women's Size 12 Women's Size 14 Women's Size 16 Men's Small Men's Medium Men's Large Men's XL Men's 2XL Men's 3XL Tell Us About Yourself* Please provide us a short 30 word bio of yourself. This is used in various locations on our website. An example is "Hi my name is Steve. I work at Sydney Adventist Hospital in the Intensive Care Unit. I love travelling, and mountain bike riding in my spare time. Passport Number* Passport Nationality* Australian Afghan Albanian Algerian American Andorran Angolan Antiguans Argentinean Armenian Austrian Azerbaijani Bahamian Bahraini Bangladeshi Barbadian Barbudans Batswana Belarusian Belgian Belizean Beninese Bhutanese Bolivian Bosnian Brazilian British Bruneian Bulgarian Burkinabe Burmese Burundian Cambodian Cameroonian Canadian Cape Verdean Central African Chadian Chilean Chinese Colombian Comoran Congolese Costa Rican Croatian Cuban Cypriot Czech Danish Djibouti Dominican Dutch East Timorese Ecuadorean Egyptian Emirian Equatorial Guinean Eritrean Estonian Ethiopian Fijian Filipino Finnish French Gabonese Gambian Georgian German Ghanaian Greek Grenadian Guatemalan Guinea-Bissauan Guinean Guyanese Haitian Herzegovinian Honduran Hungarian I-Kiribati Icelander Indian Indonesian Iranian Iraqi Irish Israeli Italian Ivorian Jamaican Japanese Jordanian Kazakhstani Kenyan Kittian and Nevisian Kuwaiti Kyrgyz Laotian Latvian Lebanese Liberian Libyan Liechtensteiner Lithuanian Luxembourger Macedonian Malagasy Malawian Malaysian Maldivan Malian Maltese Marshallese Mauritanian Mauritian Mexican Micronesian Moldovan Monacan Mongolian Moroccan Mosotho Motswana Mozambican Namibian Nauruan Nepalese New Zealander Nicaraguan Nigerian Nigerien North Korean Northern Irish Norwegian Omani Pakistani Palauan Panamanian Papua New Guinean Paraguayan Peruvian Polish Portuguese Qatari Romanian Russian Rwandan Saint Lucian Salvadoran Samoan San Marinese Sao Tomean Saudi Scottish Senegalese Serbian Seychellois Sierra Leonean Singaporean Slovakian Slovenian Solomon Islander Somali South African South Korean Spanish Sri Lankan Sudanese Surinamer Swazi Swedish Swiss Syrian Taiwanese Tajik Tanzanian Thai Togolese Tongan Trinidadian or Tobagonian Tunisian Turkish Tuvaluan Ugandan Ukrainian Uruguayan Uzbekistani Venezuelan Vietnamese Welsh Yemenite Zambian Zimbabwean Passport Expiry Date* Airline Seating Preference When booking your flights, we pass this information to our travel providers. We cannot guarantee your seating preference, but we try to accommodate where possible. No Preference With Team Members Window Aisle Airline Dietary Preference When booking your flights, we pass this information to our travel providers. Meals options vary per airline and may not always be available, but we try to accommodate your preferences where possible. No Preference Vegan Vegetarian Lacto-Ovo Meal Gluten Free Hindu Meal Diabetic Meal Kosher Meal Moslem Meal Frequent Flyer Number(s) Carrier Number Add More Frequent Flyer Details Please advise of any relevant medical history and current treatments Emergency Contact Details Next of Kin / Emergency Contact Name* Next of Kin / Emergency Contact Email* Next of Kin / Emergency Contact Phone* Team Role Travel Interests Please select which upcoming project visits you would like to volunteer for Please select the upcoming project visits you are interested in volunteering for: Cardiac Australia (March 25 - 25, 2020) Team Role* Please select the type of position that you wish to be considered for. You may select multiple categories. Burns Surgery - Project Coordinator Burns Surgery - Surgeon Burns Surgery - Surgical Assistant Burns Surgery - Anaesthetist Burns Surgery - Theatre RN Burns Surgery - Anaesthetics RN Burns Surgery - Recovery RN Burns Surgery - Ward RN Burns Surgery - Marketing and PR (including Blog Writing) Burns Surgery - Other Cardiac - Project Coordinator Cardiac - Cardiologist (Interventional Interest) Cardiac - Cardiologist (Screening -Adult) Cardiac - Cardiologist (Screening -Paediatric) Cardiac - Sonographer Cardiac - Surgeon (Adult) Cardiac - Surgeon (Paediatric) Cardiac - Surgical Assistant Cardiac - Theatre RN (Adult) Cardiac - Theatre RN (Paediatric) Cardiac - Cath Lab RN Cardiac - Anaesthetist (Adult) Cardiac - Anaesthetist (Paediatric) Cardiac - Anaesthetic RN (Adult) Cardiac - Anaesthetic RN (Paediatric) Cardiac - Perfusion (Adult)) Cardiac - Perfusion (Paediatric) Cardiac - Intensivist (Adult) Cardiac - Intensivist (Paediatric) Cardiac - Intensive Care RN (Adult) Cardiac - Intensive Care RN (Paediatric) Cardiac - CMO Cardiac - Ward RN (Adult) Cardiac - Ward RN (Paediatric) Cardiac - Biomedical Engineer Cardiac - Physiotherapy Cardiac - Pathology Cardiac - Marketing and PR (including Blog Writing) Cardiac - Other Eye Surgery - Project Coordinator Eye Surgery - Surgeon Eye Surgery - Theatre RN Eye Surgery - Orthoptist Eye Surgery - Marketing and PR (including Blog Writing) Eye Surgery - Other Women's Health - Project Coordinator Women's Health - Surgeon Women's Health - Surgical Assistant Women's Health - Anaesthetist Women's Health - Theatre RN Women's Health - Anaesthetics RN Women's Health - Recovery RN Women's Health - Ward RN Women's Health - Marketing and PR (including Blog Writing) Women's Health - Other Professional Qualifications Current Hospital* Clinical Qualifications* Briefly summarise your professional and tertiary qualifications. Referees* Please provide contact details of two referees that we can contact. Clinical Experiences* Briefly summarise your clinical experience, being specific on time period if necessary. AHPRA Registration No.* This is the number on your Australian Health Practitioner Regulation Agency Registration.If this is not relevant to the position you are applying for, please click "Not Applicable" Not Applicable Registration Expiry* Documents Maximum file size 7MB Curriculum Vitae* (.PDF, .Doc, .Docx) Your CV should simply and effectively convey your major work experience and why you should be selected as a volunteer. In many countries we must provide a CV so we can register you as a professional in that country in order to work. Please upload your CV in either Microsoft Word or PDF format. Medical Qualifications* (.PDF, .Doc, .Docx, .JPG, .JPEG) Please upload a copy of your relevant tertiary certificates. If you have an undergrad and postgrad / specialisation we would like copies of both, as in some countries we need to provide both documents for registration. The easiest way to do this is scanning the documents. If you are applying for a non-medical role, please upload a qualification relevant to the position you are applying for. Second Medical Qualifications (.PDF, .Doc, .Docx, .JPG, .JPEG) AHPRA Registration* (.PDF, .Doc, .Docx, .JPG, .JPEG) Please upload a copy of your AHPRA registration certificate. We require the actual certificate you receive, please do not scan the small pull-out card you receive. Scanned copy of your Passport* (.PDF, .Doc, .Docx, .JPG, .JPEG) Please upload a copy of the information page of your passport in either JPG, Microsoft Word or PDF format. Professional Photo (Passport Style)* (.JPG, .JPEG) We use this photo for registrations in country if we need to. It should clearly show your face and the top of your shoulders. Avoid shadows. Please upload in JPG format. Casual Photo (For your profile on our website)* (.JPG, .JPEG) In certain areas of the website we highlight you as a volunteer. There are no specific requirements on this photo like the passport photo - as long as you are clearly shown. Terms and Conditions I agree to the Volunteer Agreement. I agree to the Code of Conduct. I agree to the Child Protection Policy. Signature Please draw your signature below Clear Signature required! Volunteer Registration Submission Please wait THANK YOU FOR REGISTERING Open Heart International does not exist without volunteers, people like you that are willing to be a part of assisting the communities that we are working in. We are grateful for your interest in helping us help others. We have now received all the information you have submitted, and we will begin a short checking and verification process. Should you be accepted, you will then receive a volunteer’s login and password to this website an further instructions. You will also be subscribed to our volunteer database and email database. To get better acquainted with Open Heart International, we recommend you download our Volunteer Guide if you have not already don so. Click here to download the guide. If you have any additional questions, please feel free to contact us.