Given Name (as it appears on your passport) *
Last Name (as it appears on your passport) *
Middle Names (as it appears on your passport)
Email Address *
Country of passport you will be travelling on *
Passport Number *
Select Your Qualification
(select)Non-MedicalStudent (Medical)Student (Nursing)Nurse (AIN)Nurse (Enrolled)Nurse (Registered)inter (PGY1)RMO1 (PGY2)SRMO(PGY3)Registrar (Anaesthetic)Registrar (Emergency Medicine)Registrar (Intensive Care)Registrar (Physician)Registrar (Surgery)Registrar (Other)General PractitionerSpecialist (Anaesthetist)Specialist (Physician)Specialist (Paediatrician)Specialist (Cardiothoric Surgeon)Specialist (General Surgeon)Specialist (Gynaecologist)Specialist (Paediatric Surgeon)Specialist (Urologist)
Do you have current AHPRA registration?
Your AHPRA registration number
Do you have current medical indemnity?
Your medical indemnity company and membership number
Your current employer*
Which country would you like to volunteer in?
(select)Cook IslandsFijiKiribatiNauruPNGSamoaSolomon IslandsTongaTuvaluVanuatu
When would you like to volunteer?
(select)Jan 2019Feb 2019Mar 2019Apr 2019May 2019June 2019July 2019Aug 2019Sep 2019Oct 2019Nov 2019Dec 2018Jan 2020Feb 2020Mar 2020Apr 2020May 2020June 2020July 2020Aug 2020Sep 2020Oct 2020Nov 2020Dec 2020Anytime
Your preferred referee's name (preferably a current DAISI member or colleague or superior at work)*
Your referee's position (preferably a senior member of staff of supervisor)*
Your referee's mobile number *
Your second referee's name (can be your colleague or superior at work)*
Your second referee's mobile number *
Your second referee's position (preferably a senior member of staff of supervisor)*
Your Next of Kin (NOK) name for emergency contact *
Your Next of Kin (NOK) relationship *
Your Next of Kin (NOK) email address for emergency contact *
Your Next of Kin (NOK) address *
Your Next of Kin (NOK) mobile number *
Do you have any drug allergies?
Please list your drug allergies
Your blood type?
Please list any medications that are absolutely essential for you to take during your trip
Do you plan to purchase travel insurance when you book your flight (strong recommended)?
Do you give DAISI permission to put your profile photo or videos of you while volunteering on your daisi.com.au website?
Please briefly state why you would like to volunteer, and what you hope to get out of it. *
TERMS AND CONDITIONS
I confirm that the above entered information is accurate. As a DAISI volunteer, I understand that I will be paying my own way including flights, accommodation, and food during my visit to the South-Pacific. I am aware that medical services are limited, and that there is personal risk associated with volunteering in remote locations of the South-Pacific. I understand that it is each volunteer's responsibility to purchase travel insurance when purchasing flights to allow for cover for medical evacuation if required. I understand that it is my responsibility to visit my GP prior to volunteering to obtain all necessary vaccination and anti-antimalarial prophylaxis advice prior to my trip. I understand that attendance at formal briefing and debriefing sessions is recommended at the start and end of volunteer trips. Whilst DAISI provides advice and logistical support whenever possible, I understand that I take personal responsibility for all risk associated with volunteering in the South Pacific and that in the event of serious injury or death DAISI will not be held responsible or liable in any way.
Do you agree to the above DAISI terms and conditions for volunteering in the South-Pacific?:
Are you interested in making a difference?
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Account Name: DAISI
Account Number: 403619756
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