Volunteer Information Form

Trip you are applying for: *

Please enter Month and Day from the Upcoming Trips list on our website, or Open if undecided

Are you a returning volunteer?

Yes

No

Even if you are a returning volunteer, please update your information below.

First Name (exactly as it appears on Passport): *

Middle Name (exactly as it appears on Passport): *

Last Name (exactly how it appears on Passport): *

Date of Birth: *

Sex: *

Female

Male

Address: *

City: *

State: *

Zip/Postal code: *

Home phone: *

Cell phone: *

Email address:

T-shirt size:

Current weight:

Smaller airlines require this information.

Passport Number:

Passport Issue Date:

Passport Expiration Date:

if not US or Canadian citizen: VISA Number:

VISA Country of Origin:

VISA Expiration Date:

Dietary Preferences/Restrictions

Our teams are often dependent on our local hosts for meal preparation and we cannot guarantee that special dietary needs can be met and you may have to bring pre-made or packaged food. Every effort will be made to safeguard the food and water served for our group.

My dietary preferences/restrictions:

Vegetarian

Vegan

Serious Food Allergy

My serious food allergy:

Professional Information

Current Occupation:

Specialty:

Please describe your area of specialty.

Other (occupation):

Student:

Year of training (students):

Other (student):

Current employer/school:

Other than your professional skills, please describe any skills or talents which might be useful on this team:

Skills and Language

Do you have:

Computer skills:

Please list any computer-based skills.

Photography or Videography skills:

Please list and photo/video-based skills.

Art or Graphic Design skills:

Musical skills:

Do you speak any French or Haitian Creole?

Yes

No

Minimal

Other languages (other than English)?

Please explain how your skill set will help accomplish HUFH's mission and improve program delivery.

Medical Information and Emergency Contacts

Traveling to and working in a resource poor country like Haiti can be dangerous to those individuals with serious health issues. Having a chronic medical condition would not disqualify an individual from participating in the program, however, each applicant is considered on a case by case basis. It is ultimately up to the team leader to decide if an individual can be safely accommodated on a particular mission. Please be honest with your team leaders regarding any potential medical emergencies that could arise. All health information will be kept confidential by the team leader.

Allergies:

Medical conditions (chronic):

In the last three months, have you had any surgical procedures or been hospitalized for any reason? If so, please provide a physician’s certification that you are medically cleared to travel. *

No

Yes. A Physician's certification that I am medically cleared to travel is being emailed under separate cover.

By checking this box, I agree to notify HUFH Executive Director and my team leader if I am treated by a physician for any medical condition requiring surgery, hospitalization or emergency treatment, between now and the time my trip departs.

MEDICATIONS: Obtaining personal medications (that we do not bring with our team) is not possible as there are no retail pharmacies in Cap Haitien. All volunteers must be responsible for bringing any personal or emergency medications in ample supply.

Medications currently taking:

PSYCHOLOGICAL HEALTH: Traveling to and working in Haiti can be a very stressful experience. Please inform your team leader of any psychological or emotional conditions (such as anxiety disorders, depression, panic attacks, mood disorders) that may affect your performance as a team member on this mission (all information will be kept confidential).

Other information for team leader regarding your health and well being:

Emergency Information

Travel Health Insurance

Name of insurer:

Policy number:

Contact number:

Emergency contact #1

Relationship:

Name:

Address:

City:

State:

Zip/Postal code:

Home phone:

Cell phone:

Email address:

Emergency contact #2

Relationship:

Name:

Address:

City:

State:

Zip/Postal code:

Home phone:

Cell phone:

Email address:

Password