University of Miami
Haiti Volunteer Sign-Up
Thank you for offering to volunteer to help Haiti. Please complete all fields below on this secure webpage. When completed click the submit button."
Last Name:
(As appears on your passport)
First and Middle Name:
(As appears on your passport)
Contact phone:
Home address
Street:
City:
State:
Zip:
Date of birth:  
Email:
Languages:



Title:
Physicians Status:
(Some restrictions apply depending on your status)
Medical specialties:
If you selected Pediatrics above, please choose your sub specialty:
Medical license number (if applicable):
Are you an American citizen?
 
Country of citizenship:
UM Personnel:
 
Organization:
Emergency contact
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Phone:
Dates of availability
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Comments:
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