Cybersight Telementor Application
Please fill out this form if you would like to be able to respond to cases and questions posted by eye-healthcare professionals who need support around the world. Mentors are required to have at least 5 years of post-residence practical experience.

If instead you meant to fill out the mentee application, please click here. If you have any questions or concerns, please contact support@cybersight.org.
1.Name:



2. Contact Information


3. Institution/Hospital Name and Address






4. Role




5. Certification
* North American or European Board Certification or your country's equivalent. Required for Ophthalmologists.
6. Mentorship opportunities 





7. Please attach copies of the following required documents:








Copyright(c) 2003-16 Project Orbis International, Inc.

All worldwide rights reserved.

Orbis Telementor Agreement
Between Orbis International, Inc. and: 

Scope of Work:


I will provide Project Orbis International, Inc. (hereinafter called “Orbis”) with some or all of the following: editorial and review services of educational materials for the Orbis Telemedicine website located at URL: http://telemedicine.orbis.org (hereinafter called the Website); contributions of educational materials for the Website; partner consultation. Partner consultation includes review of patient information leading to diagnostic and treatment suggestions to be considered by the partner doctor while he/she determines case management and follow-up of patient treatment based on consultation provided to each partner.

 

Independent Contractor Status:


This agreement creates an independent contractor relationship, in which I shall act as a volunteer worker, and is not intended to, or should be construed to establish an employer-employee relationship, partnership, joint venture, agency or similar relationship. I shall not have any right or authority to assume or create any obligation or responsibility, express or implied, on behalf of or in the name of Orbis, or to bind Orbis in any manner, unless authorized in writing by a duly authorized Orbis representative. I shall not make any contrary representation to any third party. I assume full responsibility for my acts in the performance of this agreement.

 

Payment:


Telementor services are provided on a voluntary basis and Orbis offers no compensation for services provided, including, but not limited to, digital consultation (excluding travel at the request of Orbis), contribution of educational materials for the Website, service on Editorial and Review Committees, or administrative functions.

 

Termination:

Either party may terminate this agreement with written notice within 24 hours of such notice.

 

Warranty:

I warrant that I have the necessary expertise, skill and experience to provide the services under the agreement. I warrant that I will comply with representations and descriptions in respect of the Scope of Work above.

 

Confidentiality:

The nature of this relationship being one that requires access to patient information and Orbis Intellectual Property, I am bound by absolute confidentiality of information, business procedures, product profiles and other information pertaining to Orbis, unless expressly permitted for publication or dissemination.

 

1. Any information, documents, software, technology, data, manuals and other materials which relate to Orbis, its activities, business, funding or associated companies or foundations and all copies thereof supplied by Orbis or prepared, gathered or otherwise obtained by me (“Confidential Information) shall remain the property of Orbis and shall be kept confidential by me and not used by me other than for the benefit of Orbis.

 

2. I shall not transfer or divulge any Confidential Information to any other person or organization, unless:

a.     Orbis’s prior written consent is obtained; or

b.     The information is already in the public domain, other than through the default of myself; or

c.     Disclosure is required by law.

3.  I shall exercise whatever reasonable means are necessary to protect and safeguard the interest of Orbis and its Confidential Information under the laws of New York State, U.S.A. and shall otherwise comply with any other reasonable requirements of Orbis.

4.  The confidentiality requirements contained herein shall remain in full force and effect notwithstanding the expiry or termination of this Agreement.



TERMS AND CONDITIONS OF ENGAGEMENT WITH ORBIS TELEMEDICINE


1. I agree that I will use the Website only for purposes of medical evaluation, diagnosis and avocation. I agree that I will not use the Website for private and/or personal communications or solicitations of any nature, and such use of the Website may result in termination of this agreement. I acknowledge that Orbis reserves the right to remove   material from the Website in its sole discretion.

2. I understand that, in the course of my review of a patient’s case, I will have access to information of a personal   and confidential nature (“Personal Information”), including the patient’s name, birth date and medical history.

3. I agree that I will use the Personal Information solely in connection with the evaluation and diagnosis of a patient’s condition. In this regard, I may only share the Personal Information with Orbis and third parties Orbis may designate to assist in the evaluation, diagnosis and treatment of a patient’s condition.

4. I agree to maintain the confidentiality of the Personal Information.

5. I agree to defend, indemnify and hold Orbis, its affiliates, and associates including mentors and institution participating in Orbis programs, harmless for any loss, damages or costs, including reasonable attorneys’ fees and disbursements, resulting from any third party claim, action, or demand resulting from my misuse of the Personal Information or the Website.


6. I agree that patient images used by me for third party educational purposes shall not contain Personal Information that identifies the patient as an individual, such as name, birth date and medical history.

7. The laws of the State of New York, USA, will govern any dispute regarding this agreement. The parties agree to submit all disputes arising out of or in connection with this agreement to the exclusive jurisdiction of the courts of the State of New York, New York County.

The laws of the State of New York, USA, will govern any dispute regarding this agreement. The parties agree to submit all disputes arising out of or in connection with this agreement to the exclusive jurisdiction of the courts of the State of New York, New York County.

 

By signing below, I confirm that I have read, fully understand and agree to the above.



Copyright(c) 2003-16 Project Orbis International, Inc.

All worldwide rights reserved.

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