Thank you for your interest in volunteering with Sakya Care Foundation!

Please fill out the information and SELECT

1. "Joining Sakya Care Family" to become a member of Sakya Care Foundation to receive information regarding upcoming events

2. "Humanitarian Mission 2020" to sign up for medical mission trip - VIETNAM & CAMBODIA PROJECT 2020 FROM JUNE 22-JULY 4, 2020.

Your information will not be saved until you go to the very end of the page and click SAVE AND SUBMIT.

If your plans have changed, please use the RECALL MY INFORMATION button to pull up your assignments, and cancel yourself promptly

If you have any question, please don't hesitate to contact us at info@sakyacare.org

 
      If you previously registered on this webpage, we will recall your information.
Do not RECALL your information and type over it for another family member. That overlays the existing record.
 
 
Abbreviated Title   Example: Mr., Ms., Dr., Hon.
 
     
Professional Abbreviations       Example: DDS, MD, PhD
Name on Badge       List the information you want to appear on your badge.
Example: Dr. Jeff, Ms.King, Sam
 
 
  If possible, we would like to text you with occasional reminders and pertinent updates.
Mailing Address Line 1   Include apartment, suite or box number, if applicable.
Mailing Address Line 2  
 
 
 
  We recommend an email address unique to the registered volunteer instead of a shared office address or the personal address of a group leader for all group members. We will send personalized scheduling correspondence to this address.
 
        
  Establish your unique User Name. You may use your email address as your User Name unless another registered volunteer will be receiving correspondence at that same address. 
        
  Used to recall your information when you visit this site again so you can make changes and/or select additional volunteer opportunities.  Your password must be at least 6 characters.
 
       
Required Age
  I will be at least 18 years of age when I volunteer. If not, a parent or guardian will provide a signature for me when I register.
  For legal reasons these are the age restrictions for volunteering.
 
T-Shirt Size   T-Shirt style is adult unisex.
Language Fluency (other than English)
Select all that apply 		  Hold down the control key to select more than one language.
Hold down the control key and click on a selected language to de-select it.
         
Other Information
    Humanitarian medical mission agreement     By checking YES, I am agree to participate in Sakya Care Foundation's medical mission 2020 and will be responsible for all the finance for the mission trip. I am agree to: 1. Pay in full the mission trip fee (no airfare included) 2. Pay my own personal insurance for the trip. (Sakya Care will cover the health insurance during the trip) 3. Do not held Sakya Care Foundation or any volunteer personnel responsible in case of unforeseen accident
    I would like to     Pay via check: Payable to Sakya Care Foundation and send to P.O. Box 173, Midway City, CA 92655
    I would like to pay     Pay via Zelle or Venmo. Please contact us at info@sakyacare.org for more info.
    I would like to     Pay via Paypal at donation@sakyacare.org. Please remember there will be a 3% surcharge to your fee for paying via credit card
    Blood Borne Pathogen Certified     Have you taken an infection control/ blood-borne pathogen certification training?
    Vaccinated for Hepatitis B    
    Vaccinated for Hepatitis A    
    Do you have any allergies?
    Please list any allergies (food, medication, insect ect)
    Do you have any medical problem?
    Do you have any medical issue that might limit you from participate in certain activity of the mission? Please list any medical condition that you have or had
    Do you take any medication?
    Please list any medications that you are taking and need to bring with you during the mission trip
    Citizenship
    Please provide country of citizenship and place of birth, if different.
    Passport info
    Please provide us your Passport Number and Date of Expiration. Important: You need to have a passport, valid for at least 6 months AFTER the end of the trip.
    Language proficiency
    Can you speak Vietnamese and/or Cambodian? What is your level of proficiency? (A. Speak fluently + read & write. B. Speak fluently but can't read or write C. Understand little but cannot communicate freely)
    Are you from CSS youth?    
    Special requests
    Please let us know any special requests or information that you would like us to know prior to the mission. (ie vegetarian, diet restriction, same room request with other volunteer, late arrival, early leaving, motion sickness on car/air ect). We will try our best to accommodate your needs.
    Interested in traveling within the United States for mobile clinics?     If you are willing to travel to clinics further away from you but still within the United States please check this box.
          
Company / Organization   Optional, but helpful to know especially if you're coming with an office or team.
Matching
My company has a matching program
  Please indicate if your employer matches your donated time with a financial donation to the non-profit where you volunteer.
Description   Describe the program requirements and let us know how we can help - provide information for anyone we must contact and/or list any documentation you might need etc.
 
First and Last Name  
Relationship    
Phone    
   
Event Area
  Select the area appropriate to your profession / classification.
Profession / Classification
General Notes
(if needed)
 
License Number   Enter "none" if a license is optional for your profession and you do not have a license. Set the Expiration Date in the future. Please provide a copy of your license for verification process and application to practice medicine in a foreign country if you are register for overseas mission.
Expiration Date    
Prof. Liability Insurance Carrier   Professional malpractice insurance is your responsibility. Write "NONE" if you do not have any and reach out to us to learn more about being added to our insurance plan.
State of Licensure   Out-of-state providers MUST follow the procedures for out of state volunteers.

Only U.S. licensed professionals are able to volunteer as healthcare providers.
License Comment   List additional information we should know. Examples: You selected Other Professional - indicate field/specialty. Your license will renew before the clinic. You are licensed in a second field - provide license details.
     
Residency Location  
Residency Supervisor  
     

We welcome student participation at our clinics! We have three main types of student participation:

  1. Pre-Health: If you are in a pre-healthcare track (pre-med, pre-nursing, pre-dentistry, etc.), please select "General Support" as your assignment. Since you are not a licensed medical professional, we could use your help as a General Support volunteer where your tasks may range from helping in patient registration to dental sterilization, depending on your interests and our needs at the clinic. We are excited for your to get some volunteer experience with us!

  2. In Professional School - No Supervisor Present: If you are in medical, nursing, dental, etc. school yet you do not have a licensed faculty supervisor accompanying you to the clinic, you will not be able to practice patient care at the Sakya Care Foundation clinic. This means you will not be able to provide any medical services or treatments to our patients. You are welcome to sign up for your respective field's "Support" category. (i.e. Dental Support, Vision Support, Medical Support). This will allow you to assist the professionals in that clinic area by helping with patient flow, serving as a scribe to the licensed professional, etc. This is a great opportunity for your to gain shadowing experience or talk to professionals in the field you are studying while also helping the Sakya Care Foundation clinic to run smoothly. Please fill out your school's information below.

  3. In Professional School - Supervisor Present: If you are in medical, nursing, dental, etc. school and you do have a licensed faculty supervisor that will accompany you to the clinic and if you are at least over halfway finished with your program and well into clinical rotations, then you will be able to practice patient care under your faculty's supervision. However, that supervisor must contact us at: SakyaCare@gmail.com. This is how our Volunteer Coordinators will provide the correct information, discuss the requirements, and approve your school for a specific clinic. Once you have been approved, you will be able to select a student assignment that will show up as your student type and your university ("Nursing Student - University of Tennessee"). Please fill out your school's information below.
School    
Field of Study / Degree Program    
Year of Study    
Onsite Faculty Supervisor    
       
 
Event
  Signing up for more than one clinic?

Great! Finish your registration and pick your assignments for your first clinic, then click

SAVE AND SUBMIT at the bottom.

THEN, click the RECALL button at the top to pull up your record, scroll down, and pick your assignments for the second event (and repeat).
 
Event Location
---
  More detailed directions will be available prior to your arrival.
Event Email
---
  Please add this information to your safe senders/callers list.
Event Phone
---
 
Event Information
 
 
Please select an assignment for each day you plan to attend.

- Waiting Lists: if your preferred assignment is full, a waiting list option may be shown. If you choose to be on the waiting list for your preferred assignment, you will also be given the option to select an alternate assignment. If an opening becomes available in your preferred assignment, you will receive an email notice (and, if selected, a text message) automatically moving you to your preferred assignment. This will automatically cancel you from the alternate assignment.

    
Admin Code
For administrative or instructed use only.
Day Type Assignment
   
     
   
Select your profile picture   You may optionally upload a profile image. Just skip this option if you do not care to share an image. We accept GIF, JPG, and PNG images.
Your current picture
   
If you have been directed to upload a document of some kind please do so below. This is otherwise not necessary. If you register for overseas mission, please 1. Upload your passport 2. Upload your itinerary 3. Upload your visa
Document 1 Name      
Document 2 Name      
Document 3 Name      

No files have been uploaded
   
Sakya Care Foundation thanks you for volunteering. Each volunteer is required to read and sign this Volunteer Agreement and Liability Waiver as a condition of participating in the event.

CONFIDENTIALITY STATEMENT

I understand that while I am participating as a registered volunteer at the Sakya Care Foundation clinic, it is mandatory that I maintain complete privacy and confidentiality of all patients. This pertains to all present and future written and verbal communications referring to any Sakya Care Foundation clinic patient. I also understand that unless I am obtaining information strictly for patient registration, I DO NOT ASK a patient any questions regarding medical insurance coverage, Medicare, or Medicaid. With my signature on the line below, I acknowledge that I have read, understand, and agree to adhere to this policy of confidentiality for the Sakya Care Foundation clinic.

RELEASE AND INDEMNIFICATION

I hereby release and indemnify Sakya Care Foundation, a non-profit organization, and all its respective officers, directors, agents, contractors, heirs, successors, and assigns, from prosecution or presentation of any claim for bodily injury or death or for property loss or damage incurred in connection with this Sakya Care Foundation clinic or related activities. I fully understand that I am volunteering at my own risk and that due to my occupational/other possible exposure to blood or other potentially infectious materials, I may be at risk of acquiring Hepatitis B virus (HBV) infection or other blood borne pathogens. I understand if I do not have the HBV vaccine, I continue to be at risk for acquiring HBV, a serious disease. If, in the future, I want to be vaccinated with HBV vaccine, I can acquire the vaccination at my own expense.

MEDIA DISCLAIMER

I give my permission for Sakya Care Foundation, its employees, volunteer staff, agents and subcontractors, to use my likeness captured in any photographs, videotape or other similar product by means of camera or any electronic or other similar devices, to be used for any purpose whether or not published and whether or not I am aware of the fact that my likeness has been captured.

Sign in the space below:
Please use your mouse to sign on a PC or use your mobile device touch screen
 
Thank you for registering as a volunteer. Upon clicking the SAVE AND SUBMIT button, you will be emailed a confirmation of your registration/updates.
   


        
       
   
       
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