University of Miami
Haiti Volunteer Sign-Up

We have a new policy going into effect immediately: IF YOU HAVE TRAVELED TO AFRICA OR ARE PLANNING A TRIP TO AFRICA, we request that you wait a minimum period of 30 days after your return before you schedule your volunteer mission to Haiti.

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
Name:
Phone:
Dates of availability
From:
To:
Comments:
Make sure you have entered all fields above