American Pharmacists Association - Haiti Relief Volunteer Response
Thank you for your interest in volunteering to assist in the Haiti Relief Efforts.
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Type of Activity Volunteering For:
Deployment to Impacted Areas
Donate Medicines and Supplies
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First Name
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Last Name
Date of Birth
Gender
Male
Female
Passport / Alien Card
Number
Passport
Alien Card
email address:
Phone Number:
Specialty:
Length of time available:
Number
Days
Weeks
Months
Other
Possible departure date:
Desired Return Date:
Note: Within the
Other Information box
also indicate if you can read, speak and/or write French, Creole or Spanish
Other Information:
City
State
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Indicates Response Required