First Name

Last Name

Email Address

Phone Number

Business

Business Number

Please select the description that best suits you as a Licensed Health Professional: Please select the description that best suits you as a Licensed Health Professional: Not Applicable Medical Doctor Chiropractor Physiotherapist Registered Massage Therapist Psychologist/Counselor Other

Please select the description that best suits you as a Community Volunteer: Please select the description that best suits you as a Community Volunteer: Not Applicable Administration Social Work Canvassing Fundraising Event Coordination Marketing Other Social Media

To register as our Corporate Donor please select a category below: To register as our Corporate Donor please select a category below: Not Applicable Annual Financial Commitment One Time Financial Donation Materials or Products Donation Food or Rations Donation Other

Have you been associated with or volunteered for any local or international charity organizations? Have you been associated with or volunteered for any local or international charity organizations? Yes No

If Yes, please explain the local or international charity work you have been a part of.

Would you like to be considered for an international medical tour? Would you like to be considered for an international medical tour? Yes No

Please share any other information you would like us to know.

House Call for Humanity is a registered not-for-profit organization. As a part of our process you may be required to provide a background/criminal record check. House Call for Humanity is a registered not-for-profit organization. As a part of our process you may be required to provide a background/criminal record check. YES - I am able to provide a background/criminal record check NO - I am unable to provide a background/criminal record check