Team Member Application GHT 2019 Application This is a secure form. Once you have started entering your information, please do not navigate away from the page until you have submitted your application. The form will not save your information, and we don't want you to have to enter it more than once! Name* First Last Home Address* Street Address City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Email* Primary Phone Number*Alternate Phone NumberPrevious Team Membership*Have you been on an previous GRID-NEA Ghana Health Team mission? Yes, I am a returning member. No, this is my first time volunteering. When did you participate as a Ghana Health Team member?*Select all that apply. Select All November 2007 November 2008 November 2009 November 2010 November 2011 April 2013 November 2015 November 2016 November 2017 November 2018 Are you currently a licensed medical professional ?*YesNoWhat is your medical speciality?*Medical professionals, please attach a copy of your current license.*Are you currently a student?YesNoWhat is your area of study?MedicalDentalOptometryNursingPharmacyPlease list any degrees that you have earned.What is your current occupational/professional role?If you are retired, please share your most recent role.Are you a member of a local church?YesNoWhat is the name of your church?Please tell us about your faith.Please list any foreign languages that you speak.Briefly describe any previous cross-cultural experiences you have had.Professional and Education UpdatePlease tell us about any professional changes that you have experienced since last joining the Ghana Health Team. Have you pursued additional training? Has your professional role changed at all?How would you describe your general health?*ExcellentGoodFairPoorDo you have any known allergies?*YesNoPlease list your allergies.Do you have any medical conditions or physical disabilities that could limit your activities and/or prevent you and others from safely performing volunteer services in a rural, developing world context?*Medical conditions include chronic anxiety and depression.YesNoPlease list your medical conditions.Dietary Restrictions*Our hosts in Ghana can provide vegetarian options; however, if you have other dietary restrictions, you will need to pack your own food for two weeks.I have no dietary restrictions.Vegetarian: I understand that NEA can provide limited vegetarian options.Other (vegan, gluten-free, dairy-free, nut-free, etc.): I understand that NEA cannot accommodate my diet and agree to pack appropriate food and/or supplements for the two weeks.How do you see yourself contributing to this team and the team's mission?*When does your passport expire?*I don't have a passportIt expires BEFORE May 31, 2020 (next year).It expires AFTER May 31, 2020 (next year).Passport Update Needed*Travel visas to Ghana cannot be issued if your passport expires within 6 months of the mission. Your passport expires before that deadline. Please confirm that, should you be accepted, you will renew your passport by Friday, May 3, 2019. I agree that I will renew my passport before Friday, May 3. Passport Needed*Please confirm that, should you be accepted to the team, you will secure a valid passport by Friday, May 3, 2019. I agree that I will obtain a valid passport by Friday, May 3. Additional Information (Optional)You may use this space to share any additional information about yourself.Confirm that you understand GRID and NEA's Christian foundation.*GRID and NEA are Christian organizations. Volunteers are not required to be Christians, but must be willing to work as part of a team defined by Christian goals and values. I understand that GRID and NEA are Christian organizations, and I am willing to work as part of a team defined by Christian goals and values. Confirm that you understand and accept the expectations of team members.*Please read the Expectations of Team Members. Note that there has been a revision for 2019, and volunteers are asked to maintain a nonsmoking and alcohol-free lifestyle while Northern Ghana. I have read the revised Expectations of Team Members and am willing to abide by them. Confirm that you are aware of and commit to attending team meetings.*Please see the North American or UK/European volunteer information sheet to confirm team meeting dates, times and locations. I can commit to being at all team meetings. I cannot attend one or more of the meetings. Team Meeting Attendance Explanation*Please indicate which meeting dates present a challenge for you and why.Please submit a recent photo.*Should you be accepted as a team member, this photo may be used in GRID's team-related publications. Maximum 1MB.Please provide a copy of your Curriculum Vitae.*References*Please provide the name and contact information (including email address) of two references.EmailThis field is for validation purposes and should be left unchanged. Δ If you experience any technical issues in submitting your application, please contact our office coordinator.