Haiti Clinics – Postponed

Status: Postponed

Want to join this trip?

Please fill out the form below to let us know you’re interested.

Phone

This field is for validation purposes and should be left unchanged.

All Volunteers Section

Please fill out each section as it pertains to you. Submit Registration at the bottom of the page

Date(Required)

Trip / Clinic(Required)

Volunteer's Name(Required)

Email(Required)

Mobile Phone(Required)

Date of Birth(Required)

All volunteers must be over 18 years of age, with a parent / guardian, or a supervised medical or dental program.

Demographic Information(Required)

Home City State / Province / Region ZIP / Postal Code Country

Licensed Professionals Section Only

This area is for All Professionally Licensed Medical & Dental Volunteers (Including Dental Assistants). Others please continue to scroll down page.

Discipline / Profession / Position(Required)

Your Volunteer Position

Other

Professional Licensure Number(Required)

Mark N/A if you do not have a License#. Please do not put your driver's license number.

State of Licensure if other than CA- If Applicable

Country of Licensure if other than USA- If Applicable

Do you have malpractice coverage?

Are you retired?

Do you have a medical or dental specialty?

Please tell us about it

General Volunteers Section Only

Volunteers must be over 18, with parent, or enrolled and supervised by a school program.

Preferred Volunteer Area

Dental Area

Medical Area

Vision Area

Patient Support

Clinic Support

Section Break

Student Volunteers Section Only- College and High School

Volunteers under 18 must be enrolled in a faculty supervised program or with parent / guardian

School Name

Program Name

Expected Year of Graduation

Name of faculty /school supervisor

All students under 18 must have a licensed faculty supervisor on site

Transportation Section - For All

LMV has volunteer pilots who, if applicable, provide seats on their planes. There is a fuel reimbursement fee over $200

Are you interested in flying with an LMV volunteer pilot? (Availbility based on pilot's origin airport)

Yes

No - I will arrange my own travel

Note: There is a minimum fuel reimbursement fee of $200 payable to the pilot depending on the airport origin and destination.

Pilots (VIPs) Section Only

All potential volunteer pilots must hold at least an Instrument Rating & have clearance from the LMV Chief Pilot. If Interested: Tim Zils, Chief Pilot- [email protected]

Origin Airport (Pilots Only)

Tail Number

Insurance Expiration

Would you like to fly missions into Mexico? (Pilots Only)

Yes

No

Maybe

Are you able to fly into Mexico? (Pilots Only)

Yes

No

Not Sure