Full Name *

Email *

Mailing Address *

Phone *

Employment Position *

Degree, Title, or Specialties *

Do You Speak a Foreign Language? *

Yes

Foreign Languages Spoken *

Emergency Contact #1 - Full Name *

Emergency Contact #1 - Phone Number *

Emergency Contact #2 - Full Name *

Emergency Contact #2 - Phone Number *

Do You Have Allergies to Food or Medication? *

Yes

Food or Medication Allergies *

Chronic Illness and/or Physical Limitations? *

Yes

Chronic Illness or Physical Limitations *

T-Shirt Size (Select) *

SmileOnU Application fee *

$ 200

Please click/tap the amount.

Traveler Agreement & Release of Liability

I agree By checking this box, I agree to obtain my own vaccinations at least 4-6 weeks prior to the mission date. I have also read and agreed to the Traveler Agreement and Release of Liability consent as stated below.

CONSENT AGREEMENT AND LIABILITY RELEASE: I hereby release SmileOnU, its officers, employees and Board of Directors from any and all liability for any acts or omissions related or unrelated to the rendering of medical/ dental services to the patients. 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 SmileOnU. I will abide by the decisions of the leadership of SmileOnU. I understand this is a crucial element for the success and safety of all team members. I attest that the foregoing information that I have supplied is true and correct to the best of my knowledge.

I understand that this is an application for “consideration” for the SmileOnU travel team and does not guarantee me a position on the team.

1) COMMUNICATION: I agree that if I am accepted to the mission, I will check my email often for communications and instructions. I will respond in a timely manner to all emails from SmileOnU to avoid jeopardizing my position on the team.

2) TRAVEL: I understand that all transportation and accommodation decisions are made for the greater good and safety of the team, protection of medications and equipment, and for the success of the mission. Therefore, unless I am granted a special exception, I agree to travel TO the mission destination on the same flight, and lodge at the same hotel, as the rest of the team.

3) PICTURES and or VIDEOS: I agree and allow my pictures, videos or any images of me to be used for the purposes of marketing for SmileOnU.