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 *
Postal 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)intern (PGY1)RMO1 (PGY2)SRMO(PGY3+)Registrar (Anaesthetic)Registrar (Emergency Medicine)Registrar (Intensive Care)Registrar (Physician)Registrar (Surgery)Registrar (O&G)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 registration in country of origin?
Your country of origin registration number
Has your medical registration ever been suspended or cancelled?
Have you ever been convicted of a criminal offence?
Have you ever been convicted of any offence against a child less than 18 years of age (sexual or otherwise)?
Do you have current medical indemnity?
Your medical indemnity company and membership number
Your current employer*
Which country would you like to volunteer in?
When would you like to volunteer?
(select)Jan 2020Feb 2020Mar 2020Apr 2020May 2020June 2020July 2020Aug 2020Sep 2020Oct 2020Nov 2020Dec 20120Jan 2021Feb 2021Mar 2021Apr 2021May 2021June 2021July 2021Aug 2021Sep 2021Oct 2021Nov 2021Dec 2021Anytime
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 plan to purchase travel insurance when you book your flight (strongly 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.
Do you agree to the below DAISI terms and conditions for volunteering in the South-Pacific?: *
Terms & Conditions for Volunteering & DAISI Membership
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. Since December 2019 proof of measles vaccination (Yellow card it doctor’s letter) is required prior to entry to many Pacific Island countries. 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.
DAISI is a registered charity with the Australian Charities and Not for-profits Commission (ACNC)
DAISI is committed to adhering to the Australian Council For International Development (ACFID) Code of Conduct.
Doctors Assisting In South Pacific Islands (DAISI)
GPO Box 4488, Sydney NSW 2001
shop 1, 38 Pacific Hwy, St Leonard’s NSW 2065
© DAISI 2015 ABN 72 642 539 080