Volunteer Trip Application

Trip Date:*
Please select when you would like to volunteer.
- March 10 - 17, 2018 -- Run by Katie Lowe
- March 22 - 29, 2018 -- Fordham University GO Haiti -- Closed to Fordham Students only!
- July 3 - 10, 2018
Name*
First Last
Email:*
Enter Email Confirm Email
Date of Birth:*
MM
DD
YYYY
Phone Number:*
Address of Residence:*
Street Address City State / Province / Region ZIP / Postal Code Country
Occupation:*
Shirt Size:*
small, medium, large, x large, xx large
Special Skills and Qualifications:*
Please mark your skills from the list below, please note that none are necessary - just a desire to work hard in a group setting.
- Teaching/Reading
- Computer Skills
- Construction
- Gardening/Ecology
- Healthcare - Medical/Dental
- Psychiatric Professional
- Photography
- Crafts
- Music
Summary of Strengths*
Summarize special skills and qualifications you have acquired from employment, previous volunteer work, or through other activities, including hobbies or sports. Please note your primary strengths that you would add to the team and let us know if you think there are weaknesses as well.
Medical Information:*
How would you describe the state of your current health? Please include any allergies, recent or long-term sicknesses and diseases such as Diabetes and Heart Disease. Please list any current prescription drugs that you are currently taking. Thoroughly describe any health related problems with your heart, blood pressure, and/or lungs.
Do you smoke?*
Smoking is difficult on the mission trip due to circumstances of travel and working with children
- No
- Yes
Have you ever been convicted of a felony?*
Restavec Freedom Alliance reserves the right to conduct a background check.
- No
- Yes
How did you find out about Restavec Freedom Alliance?*
Agreement and Submission:*
Please carefully read the agreement below.

By submitting this application, I affirm that the facts set forth in it are true and complete. I understand that if I am accepted as a volunteer, any false statements, omissions, or other misrepresentations made by me on this application may result in a thorough background investigation.

I certify that I am at least 18 years of age and competent to sign in my own name OR, if I am under 18, that I will submit the Permission for International Travel Form, and will send it to RFA. I understand that if I am under 18, my application will not be processed without this completed form.

I do hereby certify that I am willing, physically and mentally fit, and sufficiently prepared to travel with and participate in a work project with Restavec Freedom Alliance, in the country of Haiti. Trip leaders have my permission to take me to a doctor for medical treatment, hospitalization, or emergency surgery if the need should arise. Should it be necessary for me to return home prematurely for medical reasons or due to disciplinary action, I will assume total responsibility for any additional costs incurred. Alcohol, smoking or other drug use is strictly prohibited at any point in the mission trip unless it is approved under special circumstances by the Director of BEM.

I also understand that there are inherent risks involved in any mission trips, and I hereby release Restavec Freedom Alliance, its staff and volunteers from any and all liability due to an injury, loss or damage to person or propety that may occur during the course of my involvement with Restavec Freedom Alliance.
- Yes, I agree to the agreement below.
- No, I do not agree to the agreement below.
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