Organization Registration
This form is meant for organizations who wish to join our Network doing health related work in northern Haiti. If you operate one or multiple medical facilities, fill out the facility form instead.
* Required
Basic information
What is the name of your organization?
*
This is a required question
What is the mission of your organization, and how do you fulfill this mission?
*
This is a required question
What is your mailing address and website address?
Number, Street, Town/City, State/Province, Country
This is a required question
What people should we and other organizations contact to reach you?
Person, Title, Phone number, email
This is a required question
Activities in northern Haiti
Where do you operate in northern Haiti and what do you do there?
Do you run temporary clinics with foreign teams, run classes for Haitian medical personnel, build roads, toilets, or water purification instruments, distribute food? Where do you do it?
This is a required question
Is your organization registered as an NGO in Haiti? Is your health facility registered with MSPP (Department of Health) in Haiti?
If not, are you in process? Do you need any help or advice in this area?
This is a required question
Supply needs
What supplies do you tend to need more of?
This is a required question
What supplies do you tend to have extras of?
This is a required question
Thoughts on the Cap Health Network
How has your organization benefited, if at all, from the Cap Health Network? What items, contacts, or assistance have been provided?
This is a required question
What do see as shortcomings of the Cap Health Network and ways we could be more effective?
Please be honest--we won't be offended.
This is a required question
Photos
Please attach any photos that give a sense of your work and, if possible, short descriptions of where the photo was taken, to
juline@caphealthnetwork.org
or anyone else on our team.
Thank you!
Thank you for your time in filling this out. Please let us know how we can help. Contact us at
julian@caphealthnetwork.org
(or any of our individual addresses) or by phone at (509) 3792-0060 or (509) 3441-1546.
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