University of Miami
Haiti Volunteer Sign-Up
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Last name:
First name:
Contact phone:
Home address
Street:
City:
State:
Zip:
Date of birth:
Email:
Languages:
Creole
French
Spanish
English
Other
Title:
M.D.
RN
CRNA
CVT
ARNP
CWS
Ph.D.
Support Staff
Other
Pharmacist
Pharmacy Tech
Doctor of Osteopathic Medicine
Physical Therapist
Occupational Therapist
CPO (Certified Prosthetist/Orthotist)
CP (Certified Prosthetist)
CO (Certified Orthotist)
EMT – Paramedics
Physicians Assistant
CNA
LPN
X-Ray/Surgical Technician
Computer Technician
Lab Technician
Engineer
Certified Respiratory Therapist (CRT)
Registered Respiratory Therapist (RRT)
Physicians in Training (e.g. Intern, Resident, PGY):
Intern
Resident
PGY - 1
PGY - 2
PGY - 3
PGY - 4
PGY - 5
Medical specialties:
Other
Acute Care
Amputee
Anesthesiology
Bariatric Surgery
Biomedical Engineering
Burns
Cardiology
Cardiothoracic Surgery
Cellular Transplantation
Certified Respiratory Therapist (CRT)
Clinical Pharmacology
Colon & Rectal Surgery
Dermatology
Doctor of Osteopathic Medicine
Emergency Medicine
Endocrine Surgery
Endocrinology/Diabetes/Metabolism
Family Medicine
Gastroenterology
General Internal Medicine
General Surgery
Gerontology & Geriatric Medicine
Hematology/Oncology
Hepatology
Infectious Diseases
Kidney & Pancreas Transplantation
Laboratories
Laparoendoscopic Surgery
Liver & Gastrointestinal Transplantation
Medical Surgery
Nephrology & Hypertension
Neurological Surgery
Neurology
Obstetrics & Gynecology
Occupational Therapist
Ophthalmology
OR Circulating Nurse
OR Scrub Nurse
Oral & Maxillofacial Surgery
Orthopaedics
Otolaryngology
Pathology
Pediatric Surgery
Pediatrics
Pharmacist
Pharmacy Tech
Philanthropy
Plastic & Reconstructive Surgery
Psychiatry & Behavioral Sciences
Pulmonary, Critical Care & Sleep Medicine
Radiation Oncology
Radiology
Registered Respiratory Therapist (RRT)
Rehabilitation Medicine
Rheumatology & Immunology
Spinal Cord Injury
Surgical Oncology
Trauma & Surgical Critical Care Services
Urology
Vascular & Endovascular Surgery
Vascular Access
Wound Care
If you selected Pediatrics above, please choose your sub specialty:
Other
Anesthesia
Critical Care
CRNA
General Surgeon
Generalist
OR Nurse
Pharmacist
Plastic Surgeon
RN
Scrub Technician
Surgeon
Medical license number (if applicable):
Are you an American citizen?
Yes
No
Country of citizenship:
Passport number:
Passport expiration date:
UM Personnel:
Yes
No
Organization:
Emergency contact
Name:
Phone:
Dates of availability
From:
To:
Comments:
Make sure you have entered all fields above