Primary Application Play Pause Unmute Mute Application Contact Name * Name First First Last Last Email * Details for Application When will you travel? Will you be leaving early on Saturday? * Yes No Will you be purchasing your own flight? * Yes No Preferred city of departure * Address * Address Address Address City City State/Province State/Province Zip/Postal Zip/Postal Country AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCôte d'IvoireCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthelemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Personal Information Phone Number * (Example: 00-1-212-324-4152). Date of Birth * Gender * Male Female Name as it appears on your passport * Please enter your name exactly as it appears on your passport. The name on your ticket must match the name on your passport or you will not be allowed to travel. Passport Number * Country of issuance * Passport expiration date * Emergency Contact Please enter the name, phone number and relationship of a person NOT traveling with you that we may contact in case of emergency. A valid phone number is required. Emergency Contact Name * Relationship * Phone Number * Email * Certifications What is your current employment status? * Employed Unemployed Self-Employed Student Name of Employer * if not applicable, please enter ‘N/A’. Do you speak Spanish? * No Yes Some Conversational Please list all relevant specialties or certifications Nurse Nurse Practitioner / PA General Surgeon Physician Plastic Surgeon Ophthamologist OB/GYN ACLS Dentist Non-Medical Food Allergies or Dietary Restrictions Do you have any food allergies or dietary restrictions? * Yes No Please list your food allergies or dietary restrictions Health Issues Do you have any health issues? * Yes No Please list any health issues and medications you are currently taking. Blood Type * Have you ever been charged with a crime or misdemeanor? If yes, please explain. * Please briefly describe any previous international volunteer experience. * If not applicable, please enter ‘N/A’. How were you referred to HELPS? Family Friend Coworker Comments/questions Please upload a copy of your valid passport. If you’re a physician, please Read below on how to submit your credentials. * Drop a file here or click to upload Choose File Maximum file size: 30MB IMPORTANT: Maximum file size is 30MB. If you are unable to submit documents at this time, your file exceeds size limitations, or you have more than one document to submit, please do not resubmit your application. INSTEAD, PLEASE EMAIL THE DOCUMENTS SEPARATELY TO: info@helpsintl.org. Please include your team’s number in the subject line of the email. Please review the terms of service including the code of conduct, liability release and statement of purpose. * I agree with the terms of service Read our Terms of Service ATTENTION PHYSICIANS: You must submit copy of the following documents to qualify for the trip: VALID PASSPORT, VALID MD LICENSE, COPY OF MD DIPLOMA, COPY OF CV/RESUME, COPY OF NATIONAL BOARD CERTIFICATE IF APPLICABLE. (Returning physicians only need a copy of your current medical license) Drop a file here or click to upload Choose File Maximum file size: 30MB Passport must be valid for 6 months from departure; MD license must be valid through the duration of the trip. If your file is larger than 30MB, please email files to teams@michiganhelps.org. If you are human, leave this field blank. Apply