MISSION 15 LOCAL (CAMBODIA) STUDENT VOLUNTEER APPLICATIONPlease enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Kampong Chhnang January 30 - February 7, 2027 This application is for medical students in Cambodia only. Given high volume of applicants, consideration only given to year 5/6/7 in dental and medical programs, year 4/5 in pharmacy program. APPLICANTLast Name *First Name *DOB *You can optionally key in the year instead of using the mouse. Select the year first and then type in the year.Gender *MaleFemalePhone *Email *University / School *Graduation Date( Leave blank if not graduated ) You can optionally key in the year instead of using the mouse. Select the year first and then type in the year.Field of Study *MedicalPharmacyDentistryOtherYear of Study *1st2nd3rd4th5th6th7thEnglish proficiency in speaking *Very GoodIntermediatePoorEnglish proficiency in writing *Very GoodIntermediatePoorSpecial skills, hobbies, and areas of interests in general *Emergency Contact: Name *FirstLastEmergency Contact Relationship *e.g., spouse, child, parent, grandparent, uncle, aunt, friend, etc.Emergency Contact Phone *Emergency Contact EmailTown / City / Province *Write a paragraph in English to tell us why you would like to join the Mission. -- AI enhanced essay is NOT allowed. -- *Please avoid AI enhanced essay. If detected, your application will be VOIDED !!Curriculum Vitae Drag & Drop Files, Choose Files to Upload If you have multiple files, please zip them up into one file.Scrub Size *SMLXLXXLNONE (I have from previous missions)Please kindly use previous CHPAA mission scrubs to defer funds for CHPAA missions.A Headshot Photo for ID Badge * Drag & Drop Files, Choose Files to Upload If possible, please name your file as such: BADGE-LastName-FirstName i.e., BADGE-Smith-Joe.jpg QUESTIONNAIRESHow did you hear about CHPAA Mission? *Describe your personal strengths and weaknesses with regards to assisting on the mission *Have you been to other missions? *YesNoIf yes, list the organizations and the provinces *What best describes your health? *GoodFairVOLUNTEER CODE OF CONDUCT 1. Support the vision of the CHPAA. 2. Uphold the highest personal and professional conduct in mission assignment, treat patients and families with dignity and compassion, display mutual respect to fellow volunteers. 3. Be sensitive to local beliefs, respectful of local traditions, culture and religions. 4. Work collaboratively with local health professionals, encourage exchange of ideas and knowledge, treat our hosts with courtesy and respect at all times. 5. Make no judgment or criticism of the local facilities or their way of doing things. 6. Refrain from making political statements and criticism of the host government and its officials, from participating in any activity or making any remarks that reflect negatively on this CHPAA mission. 7. Do not promise any CHPAA supplies, equipment or medications to a particular patient, health facility, group or individual. Also, refrain from taking supplies, equipment or medications at the conclusion of the mission. 8. Conserve supplies and medications. These are donated or purchased with donated funds. They are expensive and sometimes impossible to replace locally. 9. If unable to fulfill your assignment for any reason and need to be absent, please inform and discuss promptly with mission leaders. 10. If you know you will have a late arrival or early departure from the mission, we MUST know one month in advance in order to cover all volunteer positions at all times. 11. Pay attention to your own health needs and personal safety at all times. Please do not engage in any activities that can jeopardize your health or safety. 12. Be flexible during the mission. Remember that the mission was organized 100 percent by volunteers. When things go wrong, try to help. 13. The CHPAA designated uniform and ID badge must be worn at all times during the mission work. 14. Volunteers are expected to represent CHPAA with professionalism, neutrality, and cultural sensitivity at all times while participating in mission-related activities. The wearing or display of attire, accessories, symbols, or messages that could be interpreted as political advocacy, endorsement, or divisiveness is inconsistent with CHPAA’s mission and values and is not aligned with the obligations of a nonpartisan charitable organization under Section 501(c)(3) of the Internal Revenue Code. Agreement *I have read and agree to the Volunteer Code Of Conduct Agreement.WAIVER AND RELEASE OF LIABILITY I hereby release the Cambodian Health Professionals Association of America (CHPAA), its officers, and Board of Directors from all liability for any acts or omissions related to the rendering of medical services to the patients in Cambodia, in connection with the medical mission from January 30 to February 7, 2027. I fully understand that the mission has risks of accident, injury or disease, which may be caused by my own actions or inactions, the actions or inactions of CHPAA or others, or the conditions at the locations where the mission will take place. There may be other potential risks either not known to me or not readily foreseeable now. I fully accept and assume all such risks and all responsibility for losses or damages I may incur due to my participation in the mission. I certify that I am qualified, in good health and in proper physical condition to participate in the mission. I further hereby waive and release all rights and claims for loss or damage, at law or in equity, that I may have against CHPAA, its officers, volunteers and Board of Directors now or in the future for all illness, injury, loss or damage suffered by me as a result of my participation in this mission, even if the loss or damage is caused by the person I am releasing. This Waiver and Release is binding on my heirs, successors, assigns, personal representatives, administrators and executors. I certify that I have read the contents of this document, fully understand its provisions, and freely execute this Waiver and Release. Agreement *I have read and agree to the Waiver And Release Of Liability Agreement.CHPAA MEDIA AND PUBLICITY RELEASE I give the Cambodian Health Professionals Association of America (CHPAA), and other agents acting on behalf of CHPAA, including any photographer or videographer, permission to use my name, likeness, image, voice, and/or appearance as such may be embodied in any pictures, photos, video recordings, audiotapes, digital images, and the like, taken or made on behalf of CHPAA program activities. I agree that CHPAA have complete ownership of such pictures, including the entire copyright, and may use them for any purpose consistent with CHPAA’s mission. These uses include, but are not limited to illustrations, bulletins, exhibitions, videotapes, reprints, reproductions, publications, advertisements, and any promotional or educational materials in any medium now known or later developed, including the Internet. I acknowledge that I will not receive any compensations, etc. for the use of such pictures, etc., and hereby release CHPAA and their agents and assigns from any and all claims which arise out of or are in any way connected with such use. Agreement *I have read and agree to the Media And Publicity Release Agreement.Media And Publicity Release Consent *I GIVE my consent to CHPAA to use my name likeness to promote CHPAA’s programs, its affiliated partners, and/or their activities.Signature * Clear Signature Submit