Rehab Volunteer Application Form

Thank you very much for taking the time to offer to volunteer with Healing Hands for Haiti International.

The next step is to identify those who have skills, experience, and availability. Please complete the information below. We'll work with our volunteer groups and partners to schedule the appropriate personnel to effectively respond to the needs identified.
Please complete the entire volunteer form, review carefully and submit.





Preferred Contact Method

Daytime PhoneEvening PhoneMobile PhonePrimary EmailSecondary Email

Profession

If your field of expertise is not listed below, please complete our 'Non-Rehab Volunteer' application form.

Physician (PM&R)Rehab NursingPhysical TherapistOccupational TherapistCertified OrthotistCertified ProsthetistCertified Prosthetist & OrthotistP&O TechnicianWheelchair TechnicianSpeech Language Pathologist

License Number

Please add your complete professional license number and the issuing authority. You will be unable to work in Haiti without a valid and active professional license. If your field is not licensed (e.g. prosthetic tech) please add your area of expertise.*


Have you previously volunteered in Haiti?
YesNo

With which organization?

Language

Please select language(s) you speak. This means you can function in this language without translator assistance.

First Language

FrenchEnglishCreole

Other Languages

FrenchEnglishCreole

Required Documents

Upload Resume/CV:

We require your resume to begin processing your application.*

Reference Letter 1:

We require one letter of reference to complete your application, but we prefer two.*

Reference Letter 2:

Availability

We need to know your approximate dates of availability so we can plan for and fulfill our vacancies. For example, if you would like to travel to Haiti for 2 weeks in mid March 2011, then select 'March', '2011', 'Second Week', and '2 Weeks'. Your application will then be used to fill needs in this period. Our Volunteer Coordinators will contact you and work with you to select your final dates of availability. The need in Haiti is constant throughout the year, however, some periods are more popular than others for our volunteers. Traditionally the period from mid-January to April has the most applicants.

Month (required)

Year

Week:

Select the starting week in which you are available.*
First WeekSecond WeekThird WeekFourth WeekFifth Week

Length of stay:

Indicate how many weeks you are available.*

2nd Choice:

Select the starting week in which you are available.

2nd Choice Length of Stay:

Indicate how many weeks you are available.
1 Week2 Weeks3 Weeks4 Weeks5 Weeks or more

Notes

Add any additional information here, such as if you have a preferred travel group or friend you would like to volunteer with.

I wish to receive program updates from Healing Hands for Haiti


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