Restoring Smiles - Changing Lives
A dental & development charity working towards a world free from dental pain

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Bridge2Aid Dental Volunteer Programme - Application Form

* Required Fields

Personal Information*
Surname
First & Middle
Name as stated on passport
Title
Date of Birth Gender GDC No.
Nationality
Special Diet? No
Vegan
Full Vegetarian
Lacto Ovo Vegetarian
Lacto Ovo Vegetarian + Fish
Other – please specify  
Food allergies? Yes
No
Address(incl post code)
Telephone
Mobile
Email

Professional Qualifications
Date Details

Work Experience – last three employers
Date Details Employer Address

I wish to work on the Tanzanian DVP as a Dentist Dental Nurse

Previous Cross-Cultural Experience (including recreational)
Date Destination Activities

Please explain your reasons for applying

Please write a couple of paragraphs about your interests, hobbies,
what motivates you, your strengths and weaknesses.

Trip Dates*
Please indicate which trip you would like to take part in from the trips outlined on the web site. If you do not have a preference, then write ‘no preference.’ Whilst we aim to meet your trip preference a place is not guaranteed until after your interview. In the event of a preferred trip being full, we operate a waiting list. Please let us know at your interview whether you would be able to participate in a trip at short notice, should a place become available.
Yes No
All applicants must attend an interview- We will contact you with appropriate dates once we have received your application.
Please indicate which Interview Centre you would prefer –
South/Reigate Derby/Midlands

Referees

Please supply details of two referees, one personal and one professional. If your application is successful we may take up these references. Both referees should have known you for a minimum of 12 months.

1) Professional Referee
2) Personal Referee (not a relative please)

Professional Referee
Surname
First & Middle
Title
Address(incl post code)
Telephone
Fax (if available)
Email

Personal Referee
Surname
First Name
Title
Address(incl post code)
Telephone
Fax (if available)
Email

Where did you hear about the DVP?

Medical Questionnaire – STRICTLY CONFIDENTIAL

Name

In the event of you becoming ill or suffering an accident whilst on placement, the following information will be made available to the attending medical personnel. Please complete each section fully and accurately, and sign the declaration at the end. All information will be treated in the strictest confidence.

Immunisation Record
Please provide an accurate record of all listed immunisations including the month and year.
TYPE No Yes dd mm yy
Diptheria (child series of three)
Polio (series of three)
TYPE No Yes dd mm yy
MMR

If you do not know the dates of your childhood immunisations, please sign this disclaimer:

All the child immunisations above are complete to the best of my knowledge.


_________________________
Applicant Signature

_________________________
Date
TYPE No Yes dd mm yy
Polio Booster (as adult)
Diptheria (in last 10 years)
Tetanus (in last 10 years)
Typhoid
Yellow Fever
Rabies
Meningococcal Meningitis
TYPE No Yes dd mm yy
Hep A (1st in series)
Hep A (2nd in series)
Hep B (1st in series)
Hep B (2nd in series)
Hep B (3rd in series)
Varicella (Chicken Pox)

Medical History
Communicable Diseases – have you ever had any of the following?
Yes No Chicken Pox
Yes No Pertussis
Yes No Rubella
Yes No Measles
Yes No Scarlet Fever
Yes No Mumps
Yes No TB Date :
TB Skin Test Negative Positive Date :
Yes No ? Check each item Yes, No or ? (for unsure) Every item checked ‘Yes’ or ‘?’ must be explained in blank space to the right
1. Do you have any medical condition that is currently, or in the last 5 years has been treated by a doctor?
2. Do you have any allergies? Are you allergic to any medications or foods?
3. Are you on a special or restricted diet?
4. Have you ever been denied life or health insurance for any reason?
5. Have you ever had any significant illness or injuries other than those already noted ? If ‘Yes’ please specify.
Yes No ? Have you ever been diagnosed with any of the following?
Every item checked ‘Yes’ or ‘?’ must be explained in blank space to the right
Skin Cancer    • Eczema    • Skin Rash    • Hives    • Allergic Reaction    • Dermatitis
• Any Other Skin Disease?
Asthma    • Bronchitis (Recurrent Or Chronic)    • Emphysema    • Shortness of Breath
• Chronic Cough    • Pneumonia    • Hay Fever    • Tuberculosis    • Any Other Lung Disease?
Rheumatic Fever    • High Blood Pressure    • Fainting or Blackouts    • Heart Surgery
• Varicose Veins    • Heart Failure    • Irregular Heart Beat    • Heart Murmur    • Frequent Hand Or Feet Sweating    • Angina    • High Cholesterol    • Heart Attack    • Blood Clots
• Stroke    • Any Other Heart Disease.
Jaundice    • Hepatitis    • Hemia Or Rupture    • Stomach Or Duodenal Ulcer    • Liver Cirrhosis    • Divert Colitis    • Any Other Colon, Liver Or Stomach Disease?
Kidney Failure, Disease Or Insufficiency    • Kidney Stone    • Kidney Or Bladder Infection    • Bladder Polyps Or Tumour    • Loss Of Bladder Control    • Any Other Kidney Or Bladder Disease?
Depression    • Sleep Disorder    • Neuropathy (Nerve Pain)    • Numbness Or Abnormality In Arms or Legs    • Dizziness Or Vertigo    • Epilepsy Seizures    • Polio    • Stroke    • Serious Head Injury    • Nervous Breakdown    • Problems With Motion Sickness    • Nervousness    • Multiple Sclerosis    • Narcolepsy    • Severe Or Migraine Headaches    • Chronic Or Excessive Fatigue    • Paralysis Or Pinched Nerves    • Weakness    • Amnesia    • Any Other Nervous System Disorder?
Diabetes    • Thyroid Problems    • Hearing Loss    • Vision Loss    • Colour Blindness    • Glaucoma    • Any Other Eye Disease?
Blood Clotting Or Bleeding Disorder    • Anaemia    • Any Other Blood Disorder?
Cancer Of Any Kind?
Neck Strain    • Disc Condition    • Carpal Tunnel Syndrome    • Surgery (Back Or Neck)    • Foot Pain Or Problems    • Sciatica    • Fractures    • Bone Or Joint Disease    • Amputations    • Gout    • Arthritis    • Muscle Disease Or Fibromyalgia    • Back Strain    • Tendonitis, Bursitis, Joints That Lock, Catch Or Give Way    • Tingling Shoulder Strain Or Rotator Cuff Problem    • Any Other Muscle, Bone Or Joint Problem?
Alcohol Abuse, Drug Abuse or Chemical Dependency?
Prior Medical Testing
In the last 10 years, list all x-rays, blood tests, exercise tests, heart catheterizations, ultrasounds, scans, brain scans or major surgeries that are related to any significant illness or physical conditions.
Year Type of Test
Blood Transfusions: List any blood transfusions you have had, including dates and reasons.
Date Reason
Blood Type:
A B O
Positive Negative
Please note: If you have not been able to confirm your blood type before your trip, you will be required to sign a disclaimer.

Next of Kin*
Surname
First Name
Relationship
Address(incl post code)
Emergency Contact Numbers
Daytime Land line
Evening Land line
Mobile

Drug Allergies and Intolerance:

Medications Taken in the Past Five Years:

Declaration*

I, have completed this medical form to the best of my knowledge. I also understand the need to report changes in my health status of treatment rendered by a doctor prior to the Dental Volunteer Programme.

I request that this personal medical history be forwarded to Bridge2Aid in Mwanza, Tanzania so that I may be given any necessary medical attention should that become necessary or appropriate.

I certify that all statements given on this application are correct with no omissions.

In the course of my visit to Tanzania with Bridge2Aid, should it become necessary that I require medical treatment, I hereby agree to the performance of such treatment, anaesthetics and operations as, in the opinion of the attending physician, are deemed necessary.


Participant Conditions*

These Participant Conditions are made between (i) Bridge2Aid (UK registered charity No. 1092481), and (ii) the applicant who has signed these Participant Conditions below ('I').

  • I agree to pay Bridge2Aid a non-refundable Registration Fee and flight deposit of £350 (£225 Registration Fee, £125 flight deposit) within 2 weeks of being offered a place in writing. I understand that the Registration Fee and flight deposit are not transferable to future trips.
  • If accepted:
    • I agree to pay Bridge2Aid the balance of the cost of my trip as notified in writing (to cover accommodation, travel, international & domestic flights, food etc) no later than 12 weeks before departure. If then unpaid, I understand that Bridge2Aid may withdraw my place, and that the Registration Fee and flight deposit will be retained by Bridge2Aid. I also understand that the total cost of my trip is estimated to be £1,750 (including the non-refundable deposit), but that the cost may vary by up to 15% more or less than this sum, dependant on the exchange rate and flight cost.
    • I understand that I am liable for 50% of my costs if I cancel less than 12 weeks and more than 6 weeks before departure, and confirm that I will have travel insurance in place to cover this at least 12 weeks before departure.
    • I understand that if I withdraw from the trip 6 weeks or less before departure no amount of the monies paid to Bridge2Aid will be repaid, and that any monies paid are not transferrable to future trips.
    • I understand that any notice of cancellation must be given in writing to Bridge2Aid at PO Box 649, Chichester, PO19 9JB marked for the attention of Brian Strotton.
  • I confirm that:
    • I will be at least 18 years old on the date of departure.
    • I will have adequate and valid travel insurance that will cover me for the specific activities I will be undertaking, including, without limitation, emergency repatriation and repatriation of my remains. If I do not provide proof of adequate and valid travel insurance by no later than 10 weeks prior to departure, Bridge2Aid may withdraw my place. I acknowledge that Bridge2Aid may withdraw my place or oblige me to obtain further insurance if Bridge2Aid believes that my insurance cover is inadequate.
    • I will arrange adequate and valid indemnity insurance to practise in my professional capacity in Tanzania. If I do not provide proof of this at least 10 weeks prior to departure Bridge2Aid may withdraw my place. I acknowledge that Bridge2Aid may withdraw my place or oblige me to obtain further insurance if Bridge2Aid believes that my insurance cover is inadequate.
    • I do not suffer from alcohol or drug dependency, or from any chronic condition, which might become acute during my trip.
    • I do not have any criminal convictions and I hereby give my consent Bridge2Aid making a Criminal Records Bureau search.
  • I understand that:
    • In the event that any of the statements set out in paragraph 3 above are found to be untrue, Bridge2Aid shall be entitled to cancel my trip and any sums paid to Bridge2Aid prior to cancellation shall be retained by Bridge2Aid. In the event of such cancellation, I shall reimburse to Bridge2Aid any reasonable costs, losses or expenses which Bridge2Aid may incur or suffer as a result. Bridge2Aid will not be responsible for (and I agree to indemnify Bridge2Aid against) any costs, claims, losses and expenses arising including costs of repatriation e.g. flights and legal expenses.
    • Bridge2Aid shall not be liable for any changes to itineraries, schedules and accommodation.
    • I participate at my own risk and Bridge2Aid shall have no liability for any loss or damage incurred by me, however arising, or for cancellation of the visit for any reason outside its control. This exclusion of liability does not apply to liability arising in connection with death or personal injury resulting from Bridge2Aid's negligence, or from Bridge2Aid's fraud or wilful default.
    • My passport must have at least six months to run from the date I return to the UK.
    • It is my responsibility to obtain a valid visa before departure.
    • If I am refused passage and/or entry/exit to or from Tanzania, any additional costs incurred are my responsibility.
    • Bridge2Aid may, at its sole discretion, withdraw places on the visit. In the event that my place is withdrawn by Bridge2Aid, other than in accordance with paragraphs 3 b) or c) or paragraph 4 a) or as a result of a failure to comply with my obligations under these Participant Conditions, I understand that Bridge2Aid will refund my payments other than the non-refundable registration fee and flight deposit paid under paragraph 1. above.
  • I undertake that:
    • I will specify in my fundraising posters and any other materials used in connection with fundraising that I am raising funds to help cover the costs of my trip, rather than directly for Bridge2Aid. Raising funds to cover my costs is quite legitimate, but the distinction must be made as this is a Charities Commission requirement. I will also state in all fundraising posters and other materials used in connection with fundraising that any excess funds raised will be donated to Bridge2Aid.
      Money from fundraising cannot be used to cover the costs of my safari or weekend. I acknowledge that Bridge2Aid is not responsible or liable for the provision of my safari, nor for arranging any excursions or other tours or for anything that happens during the course of its provision.
    • I will pay the full balance of the cost of my trip no later than 12 weeks before the start of my trip. I acknowledge that all funds raised must be sent to Bridge2Aid to arrive before that date, and I undertake to pay an amount equal to any shortfall. I acknowledge that any funds raised less than 12 weeks before my trip cannot be refunded to me. Any funds received less than 12 weeks before my trip also cannot be put towards future trips as Bridge2Aid operate a ‘per trip’ policy on fundraising and therefore funds cannot be carried forward.
  • If I raise more money than I need to meet the costs of my trip (other than personal costs such as my safari or other tours), I understand that these funds will be used in pursuit of Bridge2Aid’s aims but they cannot be carried forward to cover the costs of future trips.
  • I agree to uphold the highest standards of professional and ethical behaviour at all times. I will adhere to Bridge2Aid’s guidance on appropriate cultural behaviour and dress during the visit, and understand that failure to do so may lead to my being excluded from activities during the visit at Bridge2Aid’s discretion, as normally exercised by the General Director or Team Leader.
  • I consent to all information provided to Bridge2Aid being passed on to Bridge2Aid's suppliers, agents, sub-contractors, employees or volunteers, whether based inside or outside the European Economic Area, for the purposes of my trip.
  • If any of these Participant Conditions is found by any Court or other competent authority to be wholly or partly unfair or unenforceable the validity of the rest of the Participant Conditions and the rest of the condition in question shall not be affected and shall remain valid and enforceable to the full extent permitted by law.
  • These Participant Conditions are governed by English law and I irrevocably submit to the non-exclusive jurisdiction of the English courts.

I apply to take part in the Bridge2Aid Dental Volunteer Programme, and agree to abide by the above Participant Conditions.

I confirm that my general state of health and fitness is good and I take full responsibility for my fitness to take part. I have read the Volunteer Policy and have complied with the medical advice including necessary inoculations and malaria prophylaxis.

  I apply to take part in the Bridge2Aid Dental Volunteer Programme, and agree to abide by the above Participant Conditions.

  I confirm that my general state of health and fitness is good and I take full responsibility for my fitness to take part. I have read the Volunteer Policy and have complied with the medical advice including necessary inoculations and malaria prophylaxis.


Application Checklist*
Please return the following:
Completed Application Form
Complete & Signed Medical Questionnaire
Signed Participant Conditions
2 x passport-sized photographs

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Bridge2Aid is a UK Registered Charity - No 1092481