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Cambodia Health Improvement Effort
Application for Interested Participants
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How did you hear about this project?
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Name
*
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Preferred Email Address
*
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Cell Phone Number
*
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City and State
*
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Do you have others interested in going with you? If yes, who?
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Which travel type do you prefer?
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You can view sample itineraries in the participant information document.
Service Only
Service and Extended Travel
Either
What current health professions licenses do you hold?
*
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What month of the year are you hoping to travel?
*
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The following are requested educational topics from the providers in Cambodia. Please select all that you may be interested in teaching:
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Infection Prevention and Sanitation
Maternal and Reproductive Care
Newborn and Infant Care
Emergency Healthcare
Non-Infectious Disease
Dental Care and Hygiene
Dermatology and Skin Care
Ophthalmology and Eye Care
Healthcare Administration
Required
Other healthcare expertise you have and may be willing to share:
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Follow the link below for information and the official application for participation. (To view this document in the correct format, please download instead of opening in Google Docs.)
https://drive.google.com/a/arisecharities.org/file/d/1FJ7ocEHHNHYMV1BN0bsMSOSVVhke7YzK/view?usp=sharing
Thank you for completing this and we are excited you are interested in participating! We will email you soon.
You may also call Julie Rhodes at 801-389-4781 or email
julier@arisecharities.org
with any questions.
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