Contact Us

Canadian Friends of DVI
Dr. Richard Nurgitz, Chairman
416-293-8063
chair@canadianfriendsofdvi.org

How YOU can Help:

Donate Now

Help raise much needed funds to provide the dental tools and supplies, as well as to keep the equipment for the clinic up to date.

Volunteer

If you are a dentist and would like to donate your time and skills to help these children, click HERE learn more.

 

 

 

Content on this page requires a newer version of Adobe Flash Player.

Get Adobe Flash player


Dental Volunteers for Israel

 

 

 

 

 

 

 

Dental Volunteers Application Form

Please fill out the following form or print and mail (PDF).

Volunteer Application Form

YOUR INFORMATION

Last Name:*

First Name:*

Gender
Male
Female

Languages Spoken: (mother tongue first)

ADDRESS

Street Address:

City/Town:

Postal Code:

Country:

CONTACT INFORMATION

E-mail:

Home Phone:

Office Phone:

Mobile Phone:

Fax:

DENTAL BACKGROUND

Dental School:

Year Graduated:

Degree:
D.D.S.
D.M.D.
B.D.Sc.
Other

Other Info:

Country of License:

License Number:

Post-Graduate Training:

Specialty Program:

Are you a member of a Dental Association/Academy?
Yes
No

Which?

Private Practice?
Yes
No

Number of Hours per Week:

Dental Clinic Address:

Do you treat children?
Yes
No

Approx. percentage of practice treating children:

OTHER

How did you find out about DVI?
Internet
Professional Association
News articles or Brochures
Professional Conferences
Another way:

Did a specific colleague refer you to DVI?

Name:

Preferred Volunteering Dates:
(note: apartments at DVI are available from Friday to Friday)
Friday of Arrival - First choice:
Friday of Arrival - Second choice:
Friday of Arrival - Third choice:

Number of weeks available to volunteer:

How many family members are joining you:

Their ages:

Comments: