Birth Date *
Address Line 2
State / Province / Region
Postal / Zip Code
Mobile Phone Number*
Home Phone Number
Passport Expiration Date*
Your Medical License (Max upload size: 2mb)Upload a copy of your medical license
Your CV (Max upload size: 2mb)Upload a copy of your CV
Passport size picture (Max upload size: 2mb)Upload Your Passport size picture (jpeg)
Are you a Medical Professional?
Tell us about your profession
Tell us about your Specialty
Are you interested in teaching?
Emergency Contact Address*
Emergency Contact Phone Number*
Course Date *
Please read the below statement carefully
I confirm that my service to Primary Care Haiti is provided totally as a volunteer. I will assume all risks to my property and to myself and hereby release Primary Care Haiti for any and all responsibility for claims or demands by heirs, my executors, administrators, assignees or me forever. I understand that my volunteer status does not make me an agent or employee of Primary Care Haiti and I shall not represent myself as such.
I agree to abide by the established rules and regulations of Primary Care Haiti while voluntarily serving in Haiti. I understand that the PCH board has the final decision-making authority and that their policies and procedures are to be executed by all volunteers in the program.
I understand that travel to Haiti involves a number of risks, including the risk of violence, serious injury, illness or death. Prior to signing this Waiver and Release Agreement, I have reviewed and understand the most recent version of the United States Department of State’s Consular Information Sheet regarding Haiti and any Travel Warnings issued for Haiti (available at www.travel.state.gov).
By submitting this form online I agree to abide by the above statement*
Date of Form Submission and Agreement to Terms*
When will you be joining us?*
Please make sure to fill out highlighted filed.
Please input valid Email in highlighted filed.
Please input 10 digit Number using (000)000-0000 format in highlighted filed.
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Help us continue and expand our medical training programs in Haiti!
Friday, December 3, 6PM to 10PM: Dinner & Exhibition TennisSaturday, December 4, 11AM to 3PM: Round Robin Tennis Tournament – come play or watch!