Provide your information in the fields below:

First Name	*
Last Name	*
Email Address	*
Phone Number	*
I can be ready to go beginning
Number of weeks I can be in Haiti		Select One: Just a weekend Up to 1 week 1 week 2 weeks 3 weeks 4+ weeks
Your home church (Name, State)
Have you served overseas before?		Yes No
If yes, what countries?
Have you been involved in disaster response?		Yes No
If yes, what countries?
Medical experience?		Yes No
If Yes, please describe		Anesthesiologist CPR/First Aid Dentist Emergency Medical Cert. Mental Health Counseling Ophthalmologist Orthopedics Pediatrics Pharmacist Registered Nurse Surgeon Other
Construction experience?		Yes No
If Yes, please describe		Damage assessment Metal construction Wood construction Plumbing Roofing Electrical Heavy machinery Fireman Engineering Other
Communication experience?		Yes No
If Yes, please describe		Photographer Videographer Journalist Other
Trauma counseling experience?		Yes No
Speak French?		Yes No
Speak Creole?		Yes No
How would you fund your trip?		Raise funds through donations Pay for it myself
Comments/Questions
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