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NOAH NY Volunteer Registration Form

Thank you for your interest in a medical mission with NOAH NY! Please complete the form below and click Submit. Please also be sure to mail a copy of your license to NOAH NY at P.O. Box 24702, Brooklyn, NY 11202 or scan and email a copy to admin@noahny.org


Personal Information
All fields marked with an asterisk (* ) are required.

First Name*

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Middle Name

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Last Name*

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Street Address 1*

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Address Line 2

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City*

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State

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Zip or postal Code*

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Country*

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Preferred Contact Number*

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Alternate Contact Number

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Email*

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Gender*

Please select Gender
Birth Date*

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In what capacity can you serve on our mission?

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REMINDER: if you are an MD, PA, RN, LPN or other type of license medical personnel and you do decide to join us on our medical mission, we will need a copy of your license for our files.

Do you speak French or Creole?
You do NOT need to speak French or Creole to go on one of our trips, this is just for our information

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Do you have any medical conditions that may interfere with travelling abroad? * This information is exclusively used for us to be aware of any conditions complicating travel for you or for use during an emergency.



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If yes, please list/explain diagnosis

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Are you a vegetarian?

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T-shirt Size please indicate the size you would prefer

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The 2010 summer medical mission will be from 6-19-10 to 7-4-10. We hope to have 2 groups that will each cover a week. We are considering a week in Port–au Prince and a week in Fort Liberte or both weeks on the North Coast (Fort Liberte, Ouanaminthe, Milot, Cap-Haitien) Please let us know your availability by making a selection below

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Emergency Contact
First Name

Please mention First Name
Last Name

Please mention Last Name
Relationship

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EmergencyPhoneNumber

Please mention Phone Number
Alternate Phone Number

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Email Address

Please mention Email Address
Volunteer Service Agreement

By checking the “I Agree” checkbox below, I hereby waive any right of recovery and release NOAH NY, their officers, officials, employees and agents, from liability related to the undersigned, arising from any and all injury to persons and damage to property, and further agrees and undertakes to indemnify, hold harmless and defend NOAH NY from and against any and all claims, damages, actions, liability and expenses including attorney’s fees and other professional fees in connection with bodily injury including death, personal injury and/or damage to property arising from or out of my activities and participation in volunteer services.

I also grant NOAH NY and its agents the right to use my picture, voice, and other reproductions of my physical likeness in connection with advertising or publicizing NOAH NY services and its activities in all forms of media in perpetuity.


Please check the above box to agree our Service Agreement

By submitting this application, I affirm that the facts set forth in it are true and complete. I understand that if I am accepted as a volunteer, any false statements, omissions, or other misrepresentations made by me on this application may result in my immediate dismissal.
Name

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Date (MM-DD-YYYY)

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Security Code

<b>Security Code</b><br />

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