Western Canada Relief For Haiti

2011 RELIEF GALA

2010 RELIEF GALA

Volunteer Registration

"I hereby offer myself to volunteer for Western Canada Relief For Haiti and I am ready to go to disaster struck areas for rapid humanitarian response. I understand the risks and dangers of working in such areas. I hereby confirm that all visits on behalf of Western Canada Relief For Haiti will be purely for humanitarian purposes and I will not engage in any business that may conflict the interest of Western Canada Relief for Haiti or jeopardize donations or the relief effort. I also confirm that I will not consume any alcohol, drugs or any other intoxicants during the relief mission."

List of items to take on a trip to Haiti

EMAIL Form Submission Completely FILL OUT form below. Press the Submit Your Volunteer Info button at the bottom of the form to submit your Volunteer Registration. You will recieve a reply from one of our representatives within a few days .

Thank you for your submission and welcome!

* Required

Last Name*

First and Middle Name*

Email Address*

- - Telephone No.*

Address*

City & Province*

Postal Code

Date of Birth

Gender

Are you able to go to Haiti? or Volunteer locally? *

Haiti

Locally

Both

If you are volunteering locally then specify days and time you can come?

How long can you go for? * We need volunteers for 2 weeks at a time.

1 Week

2 Weeks

3 Weeks

4 Weeks

Other:

What is your availability for Travel? * Minimum 1 week but preference will be given to those who volunteer for 2 weeks.

Not Available

Feb 20 - Feb 27

Feb 27 - March 3

March 3 - March 10

March 10 - March 17

March 17 - March 24

March 24 - March 31

March 31 – April 7

April 7 – April 14

April 14 – April 21

Other

Would you be able to pay your own fare? * Preference will be given to those who pay their own fare. We will arrange for accommodations and food.

Yes

No

Other:

What is your skill set? *

Doctor (MD)

Paramedic

Nurse

Firefighter / Rescue

First Aid and CPR training

Management and Leadership

Non-Medical Support

Other:

How is your health condition? *

Fit to Travel and stay in camps

I have health conditions

Other:

Level of Education *

MD

College

University

Post-Graduate

High School

Other:

Language Skills *

English Only

French Only

English and French

Other:

Passport No. (Must be valid and not expired) If you are planning to travel, then we need your passport number:

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