Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1697637325735.pdf (Bahamas)
BAHAMAS Hurricane Dorian Response, 2019 MEDICAL VOLUNTEER Full Name First Last MI Date and Time of Offer dd / mm / yyyy HH:MM Volunteer Status: ☐Approved ☐Tasked Internal Office Use Only ☐Pending ☐Declined Reason: Reason: Allocated Site: Allocation Date: dd / mm / yyyy Location GPS Coordinates Other Comments: (e.g.
reason for changing type vs the self-declaration from the team) COUNTRY: PROFESSIONAL TITLE: PERSONAL INFORMATION TIME (HOURS/DAYS) OR ESTIMATED DATE OF ARRIVAL: TIME (HOURS/DAYS) TO START OF SERVICES PROVISION: ADDRESS: EMAIL: PHONE: + country - area - phone number LOCAL PHONE: SATELLITE PHONE: Please type in one paragraph the type of collaboration offered VOLUNTEER ACTIVITY LOGISTIC SUPPORT Any logistical limitations or support required: ☐NO ☐YES Specify (e.g.
transport should include total volume and weight).

☐Self-sufficient during the whole mission PREVIOUS DEPLOYMENT EXPERIENCE (ONLY LAST THREE) YEAR COUNTRY EVENT TYPE OF RESPONSE DURATION (DAYS) EXISTING OR PREVIOUS WORKING RELATIONSHIP IN BAHAMAS ORGANIZATION LOCATION RELATIONSHIP DOCUMENTS REQUIRED NAME: ☐Professional Practice License ☐Copy of Passport ☐Curriculum Vitae ☐Medical Council ☐Nursing Council ☐Bahamas Health Professions Council Email: Signature: