Volunteer Application

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Personal & Travel Information

Name *

Birth Date *

Home Address*

Address Line 2

State / Province / Region

Email*

Postal / Zip Code

Country

City

Passport Number*

Mobile Phone Number*

Home Phone Number

Passport Nationality*

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)

Professional Interest

Are you a Medical Professional?

No Yes

Tell us about your profession

Tell us about your Specialty

Specialty Skills

Other

Are you interested in teaching?

No Yes

Emergency Contact Information


Emergency Contact*

Emergency Contact Address*

Address Line 2

City

Postal / Zip Code

Email*

State / Province / Region

Country

Emergency Contact Phone Number*

Book Other Trips


Course Date *

My Commitment


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?*

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