Medical Volunteer Application

Name*    

Email*    

Address*

City, State, Zip code*

Home Phone           

Cell Phone               

Gender  Female Male    Date of Birth

Passport No.    

Citizenship      

Language       English French Haitian Kreyol


Degree      Specialty

Employer

Clinical Experience/Interests Special Interests/Talents

Overseas experience and prior trips to Haiti


Are you taking any medications that will affect your ability to work with the medical team including medications that require refrigeration?

Any disabilities or limitations that we should be aware of?

Any dietary or religious restrictions?           

Dates you are available:

How did you hear about Rasin Foundation?

Please attach your CV:       

Please attach your license:


All applicants must sign and submit a liability release to Rasin Foundation upon acceptance to join the medical mission.