Name - First & Last

Age

Sex

Mailing Address (Street, City, State, ZIP)

Your Email

Phone Number

Religious/Spiritual Affiliation

Will you have any dietary needs? If yes, explain.

Will you have any allergies? If yes, explain.

Emergency Contact Name

Relation to you

Emergency Phone Number

Major

Have you ever traveled out of the country? If yes, where?

What would you hope to gain from this experience?

It is our goal to provide experiences for all volunteers that will further their professional/personal life goals. Please share how trip leadership and Haitian staff could help you reach these goals.

Enter The Code Below: