Street Address 2
Zip / Postal Code*
In what capacity can you serve on our mission?
Medical License #*
Nurse License #*
Please select your year in school*
Dentist License #*
Physician Assistant License #*
Pharmacist License #*
Other Please list (i.e. translator)*
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.
I speak French and Creole
I speak French, but not Creole
I do not speak French or Creole
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.
Are you a vegetarian?
EMERGENCY CONTACT INFO
VOLUNTEER SERVICE AGREEMENT
By submitting this form, 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.
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.