ICD Section VIII YDV Grant Application

APPLICATION FORM - YOUNG DENTISTS VOLUNTEER GRANT

Prior to completing this application, CLICK HERE to read the Overview of Programs.

APPLICANT DETAILS:

Title

Surname *

Given Name *

Phone (Home)

Phone (Work)

Mobile *

Email Address *

PO Box / Street Address *

City *

State

Postcode *

Country *

Dental School from which you graduated: *

Year of graduation: *

WHY ARE YOU APPLYING FOR THE ICD VOLUNTEER GRANT FOR YOUNG DENTISTS? *

DO YOU HAVE PREVIOUS VOLUNTEER EXPERIENCE WITH ANY DENTAL PROGRAMS? *

YESNO

PLEASE BRIEFLY DESCRIBE PROGRAMS In WHICH YOU HAVE PARTICIPATED. *

PLEASE DETAIL YOUR CLINICAL EXPERIENCE SINCE GRADUATION *(Give details of your range of clinical work and estimated hours.)

WHAT CLINICAL SKILLS DO YOU CONSIDER TO BE YOUR STRENGTHS? *

WHAT CLINICAL SKILLS ARE YOUR WEAKEST? *

DENTAL VOLUNTEERING PROGRAMS INVOLVE CROSS-CULTURAL TEAMWORK AND WORKING WITH LOCAL PROFESSIONALS. WHAT ARE SOME APPROACHES YOU WOULD TAKE TO ENSURE YOU ARE A VALUED TEAM MEMBER? *

WHAT CONCERNS DO YOU HAVE ABOUT PARTICIPATING IN A DENTALLY RELATED HUMANITARIAN PROGRAM? *

VOLUNTEER OPORTUNITIES

The ICD Young Dentists Volunteer grant offers applicants the opportunity to participate in the programs listed below. To assist you with your choices, please read the Overview of Programs

Indicate below – in priority order – up to three volunteer programs that you would like to be given the opportunity to participate in if you are the successful applicant for the ICD Young Dentists Volunteer grant.

WHY ARE YOU INTERESTED IN THE PROGRAMS YOU HAVE SELECTED ABOVE? *

REFEREES

Please give the names and contact details of two referees who have firsthand knowledge of your clinical skills and experience.

REFEREE 1

Title *

Surname *

Given Name *

Email Address *

City *

State

Country *

How does this referee know you? *

REFEREE 2

Title *

Surname *

Given Name *

Email Address *

City *

State

Country *

How does this referee know you? *

TERMS AND CONDITIONS

Applicants must have graduated from dental school less than ten years prior to the date on which they apply for the grant.
The grant amount is up to $3,500 AUD to cover airfares, accommodation and other expenses directly related to the volunteer experience, as approved by the Board prior to participation in the program. Receipts must be provided for reimbursement of expenses.
Participation in the selected program is subject to final approval by the program leader.
Participation in the approved program must take place within the 12 months following the awarding of the grant at times negotiated with the program leader, unless otherwise approved by the ICD Board.
The level of active participation of the grant recipient in the program is at the sole discretion of the program leader. This may mean that in certain circumstances, the grant recipient may only be an observer.
The grant recipient must adhere to the protocols and codes of conduct which apply to volunteers engaged in the program.
The grant recipient must meet local regulatory requirements in the country of the selected program, as all volunteers must do.
The recipient of the ICD Young Dentists Volunteer Grant is not eligible to apply again for an ICD Young Dentists Volunteer grant.
The grant recipient can submit receipts for additional expenses incurred following completion of participation in the program for consideration by the Board within the $3,500 limit of the grant.
The International College of Dentists has no responsibility to provide insurance for my participation in the volunteer program and is indemnified in respect of any claim made as a result of participation in the program. Participation in the volunteer program is undertaken at the participant’s own risk.
The grant recipient will provide an article and photos for an ICD Section VIII newsletter as requested by the Editor of the newsletter following participation in the program.
The grant recipient will give a presentation on his/her experience at an ICD function, if invited by the Board, with expenses to be reimbursed by ICD.

I have read and accept the Terms & Conditions *

Signature of Applicant: *

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Date: *

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