International Health Volunteers

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Member Application

Please fill out the form below and then click 'Preview' to view your information before submitting it. All required fields are in bold. All information will only be visible to other International Health Volunteers members and organizations.
Login Information
The following three fields are required. Please keep your password private.
Choose a username:
Choose a password:
Confirm password:
Contact Information
Please enter as much information as you are comfortable providing. This information will only be visible to other International Health Volunteers members and organizations. If you want the International Health Volunteers administrators to be able to see a certain piece of your contact information, but not the other members, put a check in the checkbox next to the field to make it private. The name and e-mail fields are required.
Name:
Address:
City:
State/Province:
Zip:
Country:
Home phone:
Home fax:
Work phone:
Work fax:
Pager/beeper:
Cell phone:
E-mail Address (e.g. admin@internationalhealthvolunteers.org):
Put a check here if you would like to be on our members-only e-mail list:
Profile Information
Please answer as much as possible. This information will be visible to other International Health Volunteers members.
Specialty:
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If not in a list please write below

Experience:
Availablility:
Special medical skills:
Languages:
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If not in a list please write below

Religious affiliations (if any):
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If not in a list please write below

Region or regions of interest:
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If not in a list please write below

Willingness to pay for cost of travel, accomodations, food, etc.:
Would you rather teach your skills or use them:
Willingness to include family in volunteer work:
Additional comments:

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