Earthquake Volunteer Registration

There has been a great outpouring of sympathy and request for opportunities to help the people of Haiti. On behalf of our community we say a special thank you to all. At this time the most urgent need is for medical personnel and supplies. Please click on the respective button if you would like to provide medical care in Haiti and or if you would like to donate supplies.

Contact Number: 516-809-8080

* Indicates a required field
Personal Information

*First Name:
Middle Initial:
*Last Name:
Date of Birth:
* Title:
*Specialty & sub-specialty:
*Credentials:
*Valid Passport:
*Expiration date:
(if less than 30 days advise to renew before departure)
Date available:
Duration of time availability:
*Previous experience with disaster:

Spoken languages:
Contact in U.S.A:
Name & Phone#
*Street Address:
Apt/suite:
*City:
*State
*Zip/postal code:
*Country:
*Home phone:
*E-mail:
   

 
 

We thank you for your interest and desire to volunteer. We also thank you for your patience with us as we work diligently to create and implement a response team that can manage the great outpouring of support

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