1000 Smiles (Jamaica/Grenada/St. Lucia) & Spring & Fall Sealant Project (JA) Application/Intake Form 2019
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Email *
First Name (Your LEGAL FIRST NAME) *
Name you prefer to be called on nametag *
Last Name *
Your Profession
I am a:
Please select the one week that would be your first choice to volunteer: *
In the box below, please list alternate weeks that you are available and willing to go if your first choice is not available *
Limited Two Week Spaces:                                    
The majority of our volunteer spaces are one week spaces, however we do have very limited two week spaces that are granted based on availability, volunteer seniority, clinic need, etc. If you’d like to apply for a 2 week space please send an email to papajoe@greatshapeinc.org and copy tiffany@greatshapeinc.org
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Email Address (if you are a dental student please provide us with a non-school address): *
Please note, if you are filling out an application for multiple people, PLEASE provide a unique email address for each application. We CAN NOT send multiple DocuSign packets (volunteer paperwork) to the same (one) email address. If you are a dental student you can provide us with your school email address as your alternate.    
Please provide an alternate email address in case of technical difficulties: *
Occassionally, we have technical challenges with DocuSign (especially with university emails) so it's helpful to have a 2nd email on file if you have one. If you don't have an alternate email please write N/a below.
Best Phone Number Type *
Work Phone Number *
Cell Phone Number *
Home Phone Number *
What are the best days to reach you (please note if there are days that your office is closed) *
The best mailing address to reach me is my: *
Work Address - Street *
(include apt or suite #)
City *
State/Province *
Zipcode/Postal Code *
Country *
Home Address - Street *
(include apt or suite #)
City *
State/Province *
Zipcode/Postal Code *
Country *
Select which statement applies to your volunteer experience with 1000 Smiles and/or Great Shape! Inc. *
Gender *
Birthdate *
(MM/DD/YYYY) Be sure to type this date in. Please don't use the drop down arrow because it auto defaults to the current year.
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DD
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YYYY
Including this year, how many years have you volunteered on this project? *
Ex: If this is your first year volunteering you would select "2019 will be my first year volunteering" otherwise you'll select how many years you've volunteered
T-Shirt Size *
Travel Documents *
Every visitor to Jamaica/St. Lucia is required to have a valid passport that does not expire during your dates of travel. In addition, citizens of certain countries (not including USA or Canada) MAY need a VISA. All volunteers must submit their passport number and expiration date with their Ministry of Health paperwork. If you have any questions about travel documents please contact shantelle@greatshapeinc.org. Please bubble the following now:
Please tell us about your travel docs here: *
List the country that your passport was/will be issued in: *
Passport # *
If you are waiting on your passport # you can put "PENDING" in the box below. Email your passport number to imani@greatshapeinc.org & copy tiffany@greatshapeinc.org once you've received it.
If this is your first year, how did you find out about us:
Please provide us with the specific name of volunteer, group, publication or other method that you found out about us through.
If you are a returning volunteer would you be willing to speak with a first time volunteer of your same profession about what to expect? If so, we will connect you by email and you can make arrangements to speak by phone if needed.
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Emergency Contact Information *
Name, Phone Number, Relationship
Serious Medical Conditions/Medications, Allergies we should be aware of in Case of Emergency *
You can write N/a if there are none
Roommate Preferences
There are 3 persons to a room on our project, except for couples who can pay extra to secure a private room on a space available basis. We do our best to place each volunteer in their desired clinic location, in their desired job (role), with their desired roommates and with their desired team members.  However, we ask everyone to be flexible in the spirit of the project.  By participating, you are accepting the possibility that we may not be able to meet all your preferences in the above.
Do you have 1 or 2 other roommates confirmed yet?
This means that you have talked to them and you all agree on the same thing.
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If yes, what are their names:
Will you be joining our project as a couple? If so, please provide the name of your significant other:
If Couples: 3rd project fee or bringing someone else
If you would prefer to have your privacy, if space allows and is approved, you can pay a 3rd project fee to guarantee a room for two. Please let us know which of these statements best describes your rooming situation
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If you don't have confirmed roommates, then what is your general bed time:
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Other Roommate Concerns?
Teammate Preferences:
Please tell us who you prefer to work with or any other teammate concerns:
Clinic Preferences:
Great Shape! operates 3 to 4 clinics in rural community settings within 1 hour of our host hotel. In addition, we operate a staff clinic at each Sandals hotel with 1 or 2 chairs. Please indicate by checking your preference/willingness to work at the Sandals staff clinic as noted below:
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Please note any other location preferences here:
If Dentist:
We ask all our volunteers to be flexible with work assignments and often our dentists find themselves outside of their regular "comfort zones" in terms of age groups served, procedures performed and/or equipment available to do the work. The following questions are designed to help us best place you on the project. First please select what type of dentist you are:
Procedures: How willing/comfortable are you in doing restorations and extractions.  
Comments:
For example, if you are a dentist that specializes in oral surgery or if you are a dentist that prefers working with children let us know that here.
Current dental license #
State that your current dental license is registered under:
If Hygienist:
Please tell us what kind of hygienist or any other information about your specialty or experience that you may have that will help us understand how to best place you on our teams. For example, if you are a hygienist that specializes in restorative work or loves placing sealants on children's teeth, please let us know that.
If Hygienist, are you licensed and comfortable doing restorative?
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Anesthetic?
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Do you have a Cavitron to bring with you?
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Current dental hygiene license #
State that your current dental hygiene license is registered under:
If you are a recent graduate dentist or hygienist, but do not have your license yet let us know here.
Let us know when you expect to receive your license.
If a Dental/Hygiene Student, what is the name of your dental school?
Dental Students: What year are you at the present moment?
List the procedures that you have performed in clinic prior to your participation in the program:
Ex: Cleanings, simple fillings, complex fillings, simple extractions, and surgical extractions
If Dental Assistant by profession...are you trained to do sealants?
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Do you have any other expanded functions? If so, please tell us below:
If you selected “Other”, please tell us what your profession is and what experience, if any, you have had in the dental field, international travel or humanitarian work.
If non dental professional...we ask all of our non dental professionals to be flexible with their support role. You may even be asked to change jobs in the middle of the project. Please rank the roles below in order of preference:
Sterilization: works in the clinic sterilizing instruments and general clinic support. Dental Assistant: Provides chair side assistance to dentist, comforts patients. Patient Registration: Manages the patient list and getting patients into empty chairs. Education team: Visits schools to teach oral hygiene and distribute brushes and paste. X-ray Radiography Assistant: Operates the imaging software used to view x-rays. Captures x-ray images on a digital x-ray system with the assistance of a dental professional.
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First Choice:
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Second Choice:
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Third Choice:
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Fourth Choice:
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Fifth Choice:
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Other Requests or Concerns:
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