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Haiti Volunteer Form
Thank you for contacting us regarding the humanitarian response to the earthquake in Haiti.
In order to best help the responding agencies seeking volunteers, please send us the following information:
Are you available to respond, or are you already responding? *
Available to respond
Already responding
Name *
Email *
Cell Phone *
Other Phone *
State *
*Select...
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
Washington DC
West Virginia
Wisconsin
Wyoming
-None-
Country *
*Select...
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Barbados
Bangladesh
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Botswana
Bolivia
Bosnia and Herzegovina
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, Democratic Republic
Cook Islands
Costa Rica
Cote D'Ivoire (Ivory Coast)
Croatia (Hrvatska)
Cuba
Cyprus
Czech Republic
Czechoslovakia (former)
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
France, Metropolitan
French Guiana
French Polynesia
French Southern Territories
F.Y.R.O.M. (Macedonia)
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Great Britain (UK)
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea (North)
Korea (South)
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Liechtenstein
Liberia
Libya
Lesotho
Lithuania
Luxembourg
Macau
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Monaco
Moldova
Morocco
Mongolia
Montserrat
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
Neutral Zone
New Caledonia
New Zealand (Aotearoa)
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palestinian Territories
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
S. Georgia and S. Sandwich Isls.
Saint Kitts and Nevis
Saint Lucia
Saint Vincent & the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Seychelles
Sierra Leone
Singapore
Slovenia
Slovak Republic
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
St. Helena
St. Pierre and Miquelon
Sudan
Suriname
Svalbard & Jan Mayen Islands
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
US Minor Outlying Islands
Uruguay
USSR (former)
Uzbekistan
Vanuatu
Vatican City State (Holy See)
Venezuela
Viet Nam
Virgin Islands (British)
Virgin Islands (U.S.)
Wallis and Futuna Islands
Western Sahara
Yemen
Yugoslavia
Zambia
Zaire (Congo, Democratic Republic)
Zimbabwe
TBD
Profession *
*Select..
Surgery
Anesthesiology
Nursing
Physician Assistant
Surgical Technology
Other
Profession - Other *
Specialty
Society
Society - Other *
Practice Status *
Actively Practicing
Retired
Resident
Medical Student
Other Status
Are you board certified? *
Yes
No
N/A
Prior trauma training, disaster experience, other humanitarian experience, previous work in Haiti, or enrolled in ESAR-VHP, MRC, DMAT, IMSURT, or other relevant information?
Prior Trauma Training
Disaster Experience
Other Humanitarian Experience
Previous Work in Haiti
Enrolled in ESAR-VHP
MRC
DMAT
IMSURT
Other Relevant Experience
Available on short notice for at least seven days? *
Yes
No
Do you have equipment and supplies that will allow you to be in austere settings for that long? *
Yes
No
Do you have a passport that is valid for at least six months? *
Yes
No
Are your foreign travel immunizations up to date (ie routine vaccinations (MMR, DPT, poliovirus, etc.), Hepatitis A or immune globulin (IG), Hepatitis B, Typhoid, Rabies)? *
Yes
No
Do you speak French? *
Yes
No
Do you speak Creole? *
Yes
No
Language - Other
We will add your information to our list of potential responders. Please be aware that we will consider your submission of this information as the provision of your consent to share it with trusted organizations involved in disaster response. For updates on the humanitarian response in Haiti, please visit www.operationgivingback.org, www.facs.org, and monitor the email updates from the Executive Director of the ACS, Dr. David Hoyt.
Once again, thank you for your willingness to assist with this humanitarian response.
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