NoahNy.org

News & Announcements

NOAH NY’s recent medical relief mission to Port au Prince has been a success.

Latest Events

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NOAH-NY Volunteer Registration Form

Thank you for your interest in a medical mission with NOAH NY! Please complete the form below and click Submit. Please also be sure to mail a copy of your license to NOAH NY at P.O. Box 24702, Brooklyn, NY 11202 or scan and email a copy to admin@noahny.org

Personal Information

All fields marked with an asterisk (* ) are required.

First Name* Invalid Input	Middle Name Invalid Input	Last Name* Invalid Input
Street Address 1* Invalid Input
Address Line 2 Invalid Input
City* Invalid Input	State Invalid Input	State* Invalid Input	Zip or postal Code* Invalid Input	Country* Invalid Input
Preferred Contact Number* Invalid Input		Alternate Contact Number Invalid Input
Email* Invalid Input
Gender* MaleFemale Please select Gender	Birth Date* Invalid Input Invalid Input Invalid Input

In what capacity can you serve on our mission? Invalid Input
REMINDER: if you are an MD, PA, RN, LPN or other type of license medical personnel and you do decide to join us on our medical mission, we will need a copy of your license for our files.
Specialty Invalid Input	Subspecialty Invalid Input	Medical License # Invalid Input
Expiration Date Invalid Input
Please select your year in school Invalid Input
Specialty Invalid Input	Nurse License # Invalid Input	Expiration Date Invalid Input
Dentist License # Invalid Input	Expiration Date Invalid Input
PA License # Invalid Input	Expiration Date Invalid Input
Pharmacist License # Invalid Input	Expiration Date Invalid Input
Other Please list (i.e. translator) Invalid Input
Do you speak French or Creole? You do NOT need to speak French or Creole to go on one of our trips, this is just for our information Invalid Input
Do you have any medical conditions that may interfere with travelling abroad? * This information is exclusively used for us to be aware of any conditions complicating travel for you or for use during an emergency. Yes No Invalid Input
If yes, please list/explain diagnosis Invalid Input
Are you a vegetarian? Invalid Input
T-shirt Size please indicate the size you would prefer Invalid Input

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If you’re unable to take part in the dates above, let us know what dates works best for you. Note, you must be willing to devote no less then 7 days.

Emergency Contact

First Name Please mention First Name	Last Name Please mention Last Name	Relationship Invalid Input
EmergencyPhoneNumber Please mention Phone Number		Alternate Phone Number Invalid Input	Email Address Please mention Email Address

Volunteer Service Agreement

By checking the “I Agree” checkbox below, I hereby waive any right of recovery and release NOAH-NY, their officers, officials, employees and agents, from liability related to the undersigned, arising from any and all injury to persons and damage to property, and further agrees and undertakes to indemnify, hold harmless and defend NOAH-NY from and against any and all claims, damages, actions, liability and expenses including attorney’s fees and other professional fees in connection with bodily injury including death, personal injury and/or damage to property arising from or out of my activities and participation in volunteer services. I also grant NOAH-NY and its agents the right to use my picture, voice, and other reproductions of my physical likeness in connection with advertising or publicizing NOAH-NY services and its activities in all forms of media in perpetuity.
I Agree Please check the above box to agree our Service Agreement
By submitting this application, I affirm that the facts set forth in it are true and complete. I understand that if I am accepted as a volunteer, any false statements, omissions, or other misrepresentations made by me on this application may result in my immediate dismissal.
Name Invalid Input
Date (MM-DD-YYYY) Invalid Input
Security Code Invalid Input