Volunteer Participation

Team(s) you wish to join*

Dame Marie Team (DM)
Port-Au-Prince Team (PAP)

Trips/year you wish to join*

DM Feb 2017
DM May 2017
DM Sept 2017
DM Nov 2017
PAP Feb 2017
PAP May 2017
PAP Sept 2017

Will you be traveling from Hartford to JFK?*

Yes
No

Name (as it appears on passport)*

First Last

Home Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Cell

Work

Email*

Date of Birth*

Passport*

Number	Expiration Date

Note Passport must not expire within 6 months of travel date.

Medical

Copies of passport and a digital photo must be provided. Licensed health care providers must provide a copy of their professional degree or a statement on letterhead from the professional university/school, current state license and signed statement related to claims.

If checked "Other" above, please specify

Medical Specialty

Yes
No

Medical Specialty Description

If checked "Yes", please list specialty

Retired*

Yes
No

Non-Medical

Profession	Skills

Languages Spoken*

English
French
Creole
Spanish
Other

Languages (Other)

If checked "Other" above, please specify

T-Shirt Size*

Dietary Limitations*

None
Vegetarian
Gluten-free
Other

Dietary Limitations (Other)

If checked "Other" above, please specify dietary limitations

Serious Medical Conditions*

None
Yes

If Yes, describe and list any necessary medications

Allergies*

None
Yes

Immunizations, such as Hepatitis A, Hepatitis B, Polio, Tetanus, Typhoid, etc., are recommended for travel to Haiti. Additional medical information can be obtained through your physician or a clinic specializing in international travel.

If Yes, describe

Person to Notify in Case of Emergency*

First Last Relationship

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Cell

Work

Email*

Beneficiary for Volunteer Insurance*

First Last Relationship

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Cell

Work

Untitled*

I agree to participate in the upcoming mission trip and release Medical Aid to Haiti, Inc. from any and all expenses and claims arising out or in connection with my trip to the third world. I understand that this is a voluntary humanitarian project and I am responsible for any and all personal expenses incurred relative to this mission, including but not limited to airfare, room and board, immunizations and other incidental travel costs

Signature (Upload File)

Date*

Name*

First Last

Volunteer Participation

Thank you for your interest in MATH and joining the mission team.