JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
January 2024 Trip Application
Thank you for your interest in HOF's Medical Service Trip to the Dominican Republic, scheduled for 1/11/2024 - 1/18/2024. Please fill out the following information and we will be in touch about interview selections. If you have any questions, please email
healthoutreachfoundation@gmail.com
.
* Indicates required question
Email
*
Your email
Full Name
*
Your answer
Preferred name (if different from above)
Your answer
What are your preferred pronouns?
Please check all that apply.
She/Her
She/They
He/Him
He/They
They/Them
Other:
Date of birth
*
MM
/
DD
/
YYYY
Do you have a valid passport?
*
Yes
No
When does your passport expire?
*
MM
/
DD
/
YYYY
Please list any certifications or licenses you hold and/or are pursuing.
Your answer
Do you have Spanish or Creole fluency? If so, at what level?
*
Your answer
Do you have any medical and/or clinical experience? (EMT, OR, tech, etc.) or have you had experience in international medical work? If so, please provide details.
*
Your answer
Next
Page 1 of 2
Clear form
Never submit passwords through Google Forms.
This form was created inside of Google Apps for Harvard.
Report Abuse
Forms
