Volunteer to work in Haiti
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1. Default Section
1
. Orthopaedic specialty
Orthopaedic specialty
Trauma
Amputation Surgery
Local Flap Surgery
Lower Extremity
Pediatrics
Pelvis
Spine
Upper Extremity
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2
. Full name as it appears on your passport
Full name as it appears on your passport
*
3
. Please list your degree (s)
Please list your degree (s)
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4
. Passport Number
Passport Number
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5
. Passport expiration date
Passport expiration date
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6
. Country of Citizenship
Country of Citizenship
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7
. Dates available to travel
Dates available to travel
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8
. Maximum length that you could stay in Haiti (as few as three days is acceptable)
Maximum length that you could stay in Haiti (as few as three days is acceptable)
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. Will you be traveling with a doctor's team? If so, please list all the members' names.
Will you be traveling with a doctor's team? If so, please list all the members' names.
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10
. Email address
Email address
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11
. Best phone number for non-work hours/days.
Best phone number for non-work hours/days.
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. Cell phone number
Cell phone number
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. Pager number
Pager number
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14
. Are you willing to pay your own way to fly to Haiti?
Are you willing to pay your own way to fly to Haiti?
Yes
No
Maybe
15
. Earthquake rescue experience? If so, please provide a short list of those experiences.
Earthquake rescue experience? If so, please provide a short list of those experiences.
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16
. Please indicate if you speak French (if you do not speak French, it will not disqualify you as a volunteer)
Please indicate if you speak French (if you do not speak French, it will not disqualify you as a volunteer)
Fluently
Understand some phrases
Read it
Do not speak or understand
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17
. Please list a contact name, phone number and the person's relationship to you, in case of an emergency.
Please list a contact name, phone number and the person's relationship to you, in case of an emergency.
100%
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