RETURNING VOLUNTEER APPLICATION: Midwives For Haiti

Contact Information

Birth Date*
Job Title/Professional Credentials*
Do you have any special medical conditions or known allergies of which we should be aware?*
Country*
State / Province*
Address*
City*
*
*
*
*
*
*
Email*
Confirm Email*
Phone*
Sometimes MFH likes to use volunteer names, quotes, images, or other materials to support our work and tell our story across various media channels.... Check here if you agree.*
  • Yes, I grant MFH permission.
  • No, I do not grant MFH permission.
Do you have any dietary preferences?*
  • None
  • Other
  • Vegetarian
  • Vegan
  • Gluten Free
  • Dairy Free

Your Return Visit

We want you back! Please tell us why you want to return as a volunteer.*
Date of most recent MFH Experience (mm/dd/yyyy)*
Desired trip length*
  • 1 week
  • 2 weeks
  • 3 weeks
  • 4 weeks
  • More than 4 weeks
Desired trip departure date SATURDAYS ONLY (1st choice) **mm/dd/yyyy*
Desired trip departure date SATURDAYS ONLY (2nd choice) mm/dd/yyyy*
If applicable, please describe the scope of your current medical practice.*
Please list below any activities or projects that you are interested in leading or participating in:*
T-Shirt Size*
  • S
  • M
  • L
  • XL
  • XXL
  • None of the Above
Emergency Contact Name (First and Last)*
Emergency Contact 10-digit Phone Number (0000000000 format, no dashes)*
Additional Comments

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