Follow Us on    
Partners
 Upcoming Events
 
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
Zip or postal Code*

Invalid Input
Country*

Invalid Input
Preferred Contact Number*

Invalid Input
Alternate Contact Number

Invalid Input
Email*

Invalid Input
Gender*

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.

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.



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
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.


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

<b>Security Code</b><br />

Invalid Input

Upcoming Events

News & Announcements

Events Calendar

Last month May 2013 Next month
S M T W T F S
week 18 1 2 3 4
week 19 5 6 7 8 9 10 11
week 20 12 13 14 15 16 17 18
week 21 19 20 21 22 23 24 25
week 22 26 27 28 29 30 31
Home | About Us | Get Involved | Donate | Partners | Photo Gallery | Videos | Contact Us
Copyrights © NoahNy.org | All Rights Reserved.
Web Design by Lakhani Developers