Volunteer Application - Friends of the Children of Haiti

Name *

First

Last

Date of Birth

Passport #

Address

Address Line 1

Address Line 2

City

State

Zip Code

Gender

Male
Female

Email *

Phone

Which volunteer trip would you like to be considered for? *

Medical Clinic Trip
Education Clinic Trip

How did you hear about FOTCOH?

Who were you referred by?

Why do you want to participate as a volunteer with Friends of the Children of Haiti?

Do you have any health related problems or physical limitations? If yes, please explain:

If you have previously volunteered with FOTCOH, please tell us which Team you were on:

Person to contact in case of emergency

We won't share any personal information

Name of Emergency Contact

Email

Phone

Relationship

Your chosen beneficiary

(such as “spouse”) for insurance enrollment. We won't share any personal information

Name of Beneficiary

Email

Phone

Relationship

Code of Conduct for Volunteers and the Rules of the Clinic *

I have read and agree to the Code of Conduct for Volunteers and the Rules of the Clinic.

Acknowledgement of Risks & Conditions and Waiver of Liability *

I have read and accept the following terms

An individual embarking on a venture with Friends of the Children of Haiti must understand certain risks and conditions, which will exist as a result of this venture. Because of the nature of the activities in which Friends of the Children of Haiti is engaged, an individual associated with Friends of the Children of Haiti will be exposed to certain hazards and risks. These hazards can include, by way of example and not limitation, the following: the dangers and uncertainties of travel, physical exertion, loss of sleep, physical, emotional and psychological stress, adverse weather conditions, dietary restrictions, poor living environment, together with possible exposure to disease resulting from the treatment of people needing medical assistance.
A trip to Haiti can be a physically and mentally challenging and stressful activity, requiring significant physical exertion, an ability to adjust to the conditions and circumstances described above, as well as other conditions which can be encountered in traveling and working a different part of the world, which conditions cannot be totally anticipated prior to departure.
Because of the physical challenges involved, persons with known physical limitations that may affect health and safety under the conditions described above, including but not limited to heart and lung disease and hypertension, are advised to check with a physician before participating in these activities.
I accept responsibility for my welfare.
For good and valuable consideration, the receipt and sufficiency of which is acknowledged, I release and waive any claim for injury and property damage that might result in any way to my person and/or property as a result of my association with Friends of the Children of Haiti. I agree to indemnify and hold harmless Friends of the Children of Haiti, its agents and those associated with it, from any claim for personal injury and property damage, whether now known to me, or which may hereafter become known to me.
During my time of association with the Friends of the Children of Haiti, I will be required to remain a physical condition that will allow me to respond to the challenges described above.
I agree not to take any substance, prescription or otherwise, which may adversely affect my mental or physical performance, while participating in any activities sponsored by Friends of the Children of Haiti.
I agree to follow all policies and procedures established by Friends of the Children of Haiti.

I, being of legal age and under no legal disabilities, freely and voluntarily acknowledge the above risks and conditions of my association with Friends of the Children of Haiti.

If I am selected to participate as a volunteer with FOTCOH, I will follow the policies and procedures established for the welfare of the group, follow instructions by the Team leaders and accept all conditions that support the team’s goals.