Haiti Volunteer Registry

 
The information collected in this database will be used specifically for disaster response to Haiti. Thank you for your willingness to assist.
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1. First Name:
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2. Last Name:
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3. E-mail Address:
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4. AAO ID Number:
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5. Office Phone:
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6. Mobile Phone:
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7. State:
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8. Country:
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9. Profession:
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10. I am willing to serve for:
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11. I have specialized training and/or experience in: (check all that apply)
12. In addition to English, I can speak the following languages: (check all that apply)
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13. I prefer to provide the following service(s): (check all that apply)
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14. I have experience working in a disaster area:
15. Comments:
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