Volunteer Application – PDF


    For and in consideration of being allowed to participate in the delivery of humanitarian
    aid in Cabaret-Ville and other regions in Haiti, I hereby agree:

    That I will provide true and accurate information as follows:

    Emergency Contact:

    I do hereby release and hold harmless the group “Voice of Cabaret for Health Education
    and Infrastructure (VOCHEI)”, its Officers, Directors, agents, and any other participants
    or affiliates in the Haiti Mission (collectively, the “Releases”), from and against any and
    all liabilities to me and my dependents, assigns, personal representatives, heirs and next
    of kin for any and all damages, expenses (including attorney fees), claims, judgments,
    actions or causes of action as a result of any loss or injury to my person or property,
    including death, which I may sustain or suffer during or arising out of the activities of the
    above-described event and during transportation to and from such event.

    I do hereby agree to assume all risks and responsibilities surrounding my participation in
    this event, including but not limited to any and all foreseen, unforeseen, known, or
    unknown risks to my health, safety, or professional status. I acknowledge that I have
    obtained whatever information I deemed necessary regarding any risks and have taken whatever steps in my sole judgment and discretion I have deemed appropriate to protect
    against such risks. In so doing, I have not relied upon and otherwise disclaim any advice,
    information, representations or warranties by the Releases.

    I verify that I have any and all professional licenses necessary to provide professional
    care and treatment and that those licenses are valid, clear, and active.

    I verify that I have no criminal charges or convictions or other criminal or regulatory
    disciplinary actions, either final or pending.

    I verify that I have no health conditions of which I am aware that would prevent me from
    providing services at the mobile clinic or from travel to Haiti.

    I verify that I am aware of any and all applicable travel requirements, restrictions, and
    warnings; have taken whatever precautions I have deemed necessary for my personal
    health and safety; and that I have in my possession valid travel documents and am
    otherwise authorized to travel out of the country and to provide aid services in Haiti.

    I acknowledge and agree that I am participating in this mission voluntarily and based
    upon a full and express assumption of all risks of loss, either to me personally or from
    claims of third parties; that I will not seek to recover from the Releases for any harm to
    myself or to others for which I may be liable; and that to the extent I deem it appropriate I
    have through self-insurance, insurance or otherwise, provided for protection against such

    I further acknowledge that I have read and understand this release and voluntarily sign
    this document.

    I hereby state, under penalty of perjury, that all the information I provide on this
    application is true, complete, and accurate.