Volunteer Sign-Up Form Name (as it appears on your passport): * First Last Gender — Select — Male Female Undefined Date of Birth: Passport Number (for airline): Email Address * Mailing Address (for travel insurance): Phone Number(s): Airport (s) for departure in order of preference: Character reference contact information (name, phone, email): Emergency contact information (name, phone, email): Occupation/Specialty/Skills/Interests: Years of Experience: Population(s) you can care for: Previous humanitarian mission (where and when): Languages you Speak: Are you able to be part of an organizing committee? Yes No Are you able to fulfill trip preparation assignments? Yes No Are you willing to work as a team? Yes No Are you willing to follow directions? Yes No Are you willing to show respect for other cultures? Yes No Are you willing to contribute to the success of the team? Yes No Are you able to work 10 hours/day in a hot/humid climate without AC? Yes No Are you able to lift 40-50 lbs without assistance? Yes No Are you able to hike? Yes No Are you comfortable camping? Yes No Are you willing to refrain from using alcohol or drugs during the trip? Yes No Are you willing to refrain from distributing money or goods? Yes No Are you willing to refrain from sharing personal information during the trip? Yes No Are you willing to maintain a professional, patient/provider relationship? Yes No Can you provide a digital picture of yourself for the team directory? Yes No In what specific ways can you contribute to the humanitarian mission success? (e.g. fundraising; recruit a doctor/dentist; unique skills, or experience; medical & dental supplies; travel arrangements; coordinate packing of medications/supplies/kits; fulfill pre-trip assignments; other) Note: Team members are expected to have a current passport (valid up to 6 months from trip dates), receive recommended immunizations prior to travelling to Haiti, and provide for their own travel insurance, transportation, and room and board fees. Additionally, they are expected to interview with the team leaders and attend one preparation meeting and the packing meeting prior to going to Haiti.