Cart
0
Sign In
My Account
About Us
Our Work
Partners
Get Involved
Donate
Merch
News
DONATE TO SUPPORT CHILDREN'S EDUCATION
Back
Our Mission
Our Story
Why climate and health?
Where we Work
Systems Thinking
Team
Board of Directors
Contact
Back
Community Programs
Research
Back
Our Partners
Back
Volunteer
Fellowships
Supply Donations
Become a Mentor
Sign In
My Account
Cart
0
About Us
Our Mission
Our Story
Why climate and health?
Where we Work
Systems Thinking
Team
Board of Directors
Contact
Our Work
Community Programs
Research
Partners
Our Partners
Get Involved
Volunteer
Fellowships
Supply Donations
Become a Mentor
Donate
Merch
News
DONATE TO SUPPORT CHILDREN'S EDUCATION
Traveler Registration
Required Travel Information
Name (exactly how it appears on passport)
*
First Name
Last Name
Affiliation
*
Email
*
Cell Phone
*
Country
(###)
###
####
Pronouns
*
she/her/hers
he/him/his
they/their/theirs
Date of Birth
*
MM
DD
YYYY
Passport Number
*
Required for booking the flight
Issue Date
*
MM
DD
YYYY
Expiration Date
*
MM
DD
YYYY
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
*
(###)
###
####
Primary Emergency Contact
Name 1
*
First Name
Last Name
Relationship 1
Phone 1
*
(###)
###
####
Email 1
*
Secondary Emergency Contact
Name 2
*
First Name
Last Name
Relationship 2
*
Phone 2
*
Country
(###)
###
####
Email 2
*
Safety
Allergies
*
Dietary Restrictions
*
Are you currently taking medications? If yes please list below.
*
List any past surgeries below.
*
I understand that this area is located in an earthquake zone and may be dangerous. I am in under no obligation to take part in this volunteer effort.
*
Yes I understand the risk and ramifications and understand that I am in no obligation to partake.
No I do not agree.
I give Walking Palms Global Health the right to use any photos or video footage that I may appear in for public and private usage.
*
Yes
No
Thank you!