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ROMP Volunteer Enrollment
Please complete this form to enroll in the ROMP program you have selected. If you have any questions, please direct them to Jonathan Naber, Chief Program Officer, at
jonathan@rompglobal.org
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* Indicates required question
Please select a program.
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January 12-21: Clinical Program in Ecuador
February 3-11: Clinical Program in Guatemala
March 10-18: Innovation Program in Ecuador
May 19-27: Innovation Program in Ecuador
June 15-24: Clinical Program in Guatemala
August 10-19: Clinical Program in Ecuador
August 31-September 9: Clinical Program in Guatemala
October 12-21: Clinical Program in Guatemala
Full Name
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Your answer
Mailing Address
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Your answer
Primary Phone Number
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Your answer
Alternative Phone Number
*
Your answer
Email Address
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Your answer
Do you have/will you have a passport that will be valid during the program you selected?
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Yes
No
What is your profession or current training program?
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Prosthetics/Orthotics
Physical Therapy
Occupational Therapy
Engineering
Design/Innovation
Public Health
Social Work
PM&R
Other:
If you are currently working, what is your employer and job title?
Your answer
If you are currently working, how many years of experience do you have?
Your answer
Please describe any prior international volunteer experience you have.
Your answer
Please describe any profesional specialties or special skills you have.
Your answer
Please list any languages other than English that you speak, and your level of proficiency of each language.
Your answer
T-Shirt Size:
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XS
S
M
L
XL
XXL
Dietary Preference/Allergies
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Vegetarian
Vegan
Kosher
Halal
Gluten-free
None
Other:
Full name of emergency contact.
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Your answer
Relationship with emergency contact.
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Your answer
Address of emergency contact.
*
Your answer
Primary phone number of emergency contact.
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Your answer
Alternative phone number of emergency contact.
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Your answer
Please read the Volunteer Waiver, and digitally sign in the space that follows using your full name. Please note that your digital signature constitutes your true signature.
*
Your answer
Please select today's date to sign for the Volunteer Waiver.
*
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