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VOI MSICS Training Application

Following is a brief questionnaire designed to help us help you. Your participation in this effort provides the groundwork for synergy, partnership, and effective communication. Please read the follow information, check all that apply, and give us as much detail as possible. Thank you!

Training Dates and Locations(*)
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Personal Information

Your Name
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Home Address
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City
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State
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Zip Code
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Country
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Email Address:(*)
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Phone or Cell
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fax
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Date of Birth
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Passport number
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Passport Expiration Date
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Business Information

Business Name
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Business Address
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City
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State
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Zip Code
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Country
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Business Phone
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Ext.
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Business Fax
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Office Managers Name
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Education and Experience

1. Name of Univ.or Institution
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1. Field of Study
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1. Degree Certificate
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1. Dates Attended
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2. Name of Univ.or Institution
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2. Field of Study
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2. Degree Certificate
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2. Dates Attended
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3. Name of Univ.or Institution
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3. Field of Study
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3. Degree Certificate
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3. Dates Attended
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Other Education or Experience
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Date of ABO Certification
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Sub Specialty
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Medical License Number
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Glove Size
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Please list the number of eye surgeries you have preformed in the last two years.

MSICS
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Phaco
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ECCE
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Glaucoma
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Past Participation in volunteer eye programs?
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What is your primary reason for learning the MSICS procedure?
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Clubs, Church, and Associations? Lions, Rotary, etc.
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Languages spoken?
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How did you hear about Vision Outreach International?
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Personal Emergency Information

Blood Type
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Medications:
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Allergies:
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Completed Hepatitis B Series:
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Date Completed:
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Emergency Contact Person

Person's Name:
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Relationship:
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Address
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City
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State
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Zip Code
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Phone or Cell
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Physician's Name
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Address
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City
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State
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Zip Code
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Beneficiary
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Relationship
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Phone or Cell
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I release Vision Outreach International (VOI) , its officers, trip organizers and leaders, members and team associates from responsibility for any accident, injury, sickness or death to me or any member of my family and/or loss of material items occurring as a result of any mission or training expedition. I understand and accept the personal health and safety risks involved.

I will be a guest of the host country and subject to the local laws and customs and to the policies of Vision Outreach International.

I will be working under and subject to the authority of the training Ophthalmologist or Project Director and agree to abide by his or her directives while visiting and working in the host country. I will be personally responsible for my transportation expenses, lodging, meals and any other incidental expenses. I understand that should it be necessary for me to cancel my participation, any refunds of airfare or other prepaid services will be my responsibility.

I further give Vision Outreach International officers, expedition leaders and other designated personnel my authorization to release pictures or stories about my participation in an expedition or training to the media.

I have read, understand and agree to the condition of this waiver, and do affirm that I am the person whose name appears below.

I realize that TYPING my name in the SIGNATURE BOX affirms that I have filled out this application with valid and correct information and agree to abide by its contents

SIGNATURE BOX
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