OLUOL Volunteer Form
Please fill this form out if you are interested in volunteering with the One Leg Up On Life Foundation
First Name *
As it appears on your passport
Your answer
Last Name: *
As it appears on your passport
Your answer
Contact Phone: *
Your answer
Email Address: *
Your answer
Street Address:
Your answer
City:
Your answer
State:
Your answer
Zip Code:
Your answer
For International Travel, What Is Your Desired Departure Airport?
If you know the Airport Code (LAX, ATL, ORD, etc.), please enter it
Your answer
Date of Birth: *
MM
/
DD
/
YYYY
What Languages Do You Speak?
What's Your Occupation?
Your answer
If Applicable, What is Your Medical Specialty?
(MD, RN, Ph.D, CPO, CP, OT, PT, etc.)
Your answer
Do You Have Any Professional Certifications?
Your answer
Are You An American Citizen?
If Not American, What is your Country of Citizenship?
Or Do You Hold Dual Citizenship?
Your answer
Do You Have a Religious Preference?
Your answer
Emergency Contact Name *
Your answer
Emergency Contact Phone Number *
Your answer
Emergency Contact Relationship
(Spouse, Sibling, etc.)
Your answer
Do You Have Any Medical Conditions, Allergies, or Special Requirements/Restrictions? *
Your answer
Do You Regularly Take or Are You Prescribed Any Medications?
Your answer
What Dates Are You Available to Volunteer?
Your answer
Please Briefly Describe Any International Mission Experience You Have
Your answer
Anything Else We Should Know?
Your answer
Have you visited the U.S. State Department Haiti Facts Page? (linked below) *
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