Volunteer to work in Haiti

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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

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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)

9. 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.

12. Cell phone number

Cell phone number

13. 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.