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