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Contact Information
Name
*
First Name
Last Name
Are you a licensed veterinarian?
*
select one
Yes
No
Yes, but I do not hold an active license
If you are a Veterinarian, please indicate the state(s) in which you are currently licensed to practice.
Do you hold an active DEA license?
select one
Yes
No
Yes, I do but but it is not currently active
Are you a licensed veterinary technician?
*
select one
Yes
No
Yes, but I do not hold an active license
What is your occupation and position title?
Email
*
Verify Email
*
Phone
Address
Address Line 1
Address Line 2
City
City
State
State/Province
ZIP/Postal Code
Country
Languages Spoken
Have you ever volunteered with Animal Balance before?
*
Yes - domestic
Yes - international
Yes - both domestic and international
No
Please Tell Us About You
*
Please list some of your interests, previous travel / volunteering experience, language skills, first aid, and any other relevant information or qualifications which might be useful.
Which Animal Balance Program are you interested in participating in?
*
VETAID // OPERATION POTCAKE 2024 - BAHAMAS
VETAID // GALáPAGOS ISLANDS
VETAID // ARIZONA
VETAID // CALIFORNIA
VETAID // LOUISIANA
VETAID // NEW MEXICO
VETAID // TENNESSEE
VETAID // TEXAS
Preferred Campaign Availability
*
In addition to your chosen campaign site, please let us know what your dates of availability are.
Are you fully vaccinated against COVID-19?
*
Yes
No
Partially - please explain in notes
I'm not fully vaccinated but...
Are you over 18 years of age?
*
Yes
No
Date Of Birth
(mm/dd/yyyy)
Health and Physical Fitness
Do you suffer from any illness, including but not limited to asthma, epilepsy, diabetes, allergies? Do you take any prescription drugs or over-the-counter medicines? Have you had any psychological / psychiatric illness in the last three years? If yes to any of the above, please supply more info in the box. If no, Enter N/A. *
Do you have health insurance?
Yes
No
Do you have any dietary restrictions?
Yes
No
If you chose YES please explain here.
Please check this box if you want to join Animal Balance's general mailing list
Join Animal Balance's General Email List
Please provide names and contact information for your references (3):
*
How did you hear about us?
