1. Default Section

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* 1. Orthopaedic specialty

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* 2. Full name as it appears on your passport

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* 3. Please list your degree (s)

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* 4. Passport Number

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* 5. Passport expiration date

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* 6. Country of Citizenship

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* 7. Dates available to travel

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* 8. Maximum length that you could stay in Haiti (as few as three days is acceptable)

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* 9. Will you be traveling with a doctor's team? If so, please list all the members' names.

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* 10. Email address

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* 11. Best phone number for non-work hours/days.

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* 12. Cell phone number

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* 13. Pager number

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* 14. Are you willing to pay your own way to fly to Haiti?

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* 15. 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)

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* 17. Please list a contact name, phone number and the person's relationship to you, in case of an emergency.

 
 100% of survey complete.

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