Help Haiti Volunteer Information

Members who would like to travel with UM's Project MediShare must complete two online forms, one for SEIU Local 1991 (below) and another form for Project MediShare. The link for the Project MediShare online form is on the right-hand side of this page.

Also, you must print out and complete the Liability Form located on the right-hand side of this page and fax it to our office at 305-620-1429. Thank you for your submittal!

SEIU Help Haiti - Volunteer Information

Please complete all information. Every field is required

Full Legal Name

'Full Legal Name' is required

Local Union and State

'Local Union and State' is required

Employer

'Employer' is required

REQUIRED: Can you be released by your employer if chosen to deploy?

Yes

Do you speak fluent Creole?

'Do you speak fluent Creole?' is required

Do you speak fluent French?

'Do you speak fluent French?' is required

Do you have disaster relief experience?

'Do you have disaster relief experience?' is required

If yes, what country?

'If yes, what country?' is required

Job title

'Job title' is required

License Number

'License Number' is required

Area of expertise? (such as ER, OR, Critical Care)

'Area of expertise? (such as ER, OR, Critical Care)' is required

Date of Birth

'Date of Birth' is required

Passport Country

'Passport Country' is required

Passport Number

'Passport Number' is required

Passport Expiration Date

'Passport Expiration Date' is required

Home Phone Number

- ###

####

Cell Phone Number

- ###

####

Email Address

Home Address

Address 1

Address 2

City

State / Province / Region

Postal Code

Country

Emergency Contact Name (required)

'Emergency Contact Name (required)' is required

Emergency Contact Relationship

'Emergency Contact Relationship' is required

Emergency Contact Phone #1

- ###

####

Emergency Contact Phone #2

- ###

####

Emergency Contact Email

Emergency Contact Name (secondary)

'Emergency Contact Name (secondary)' is required

Emergency Contact Relationship

'Emergency Contact Relationship' is required

Emergency Contact Phone #1

- ###

####

Emergency Contact Phone #2

- ###

####

Emergency Contact Email

Additional Comments

Preferred Dates to volunteer

'Preferred Dates to volunteer' is required

Legnth of time to volunteer

'Legnth of time to volunteer' is required

Project MediShare Online Form
Please click here to complete Project MediShare's online form.

Haiti Liability Form:
Please print out this form and fax it to SEIU Local 1991's office at 305-620-1429