Help Request Form

International Action installs chlorinators and other simple water systems. The chlorinators work without electricity but require a water tank, reservoir, or cistern with running water. Please complete this form, and we'll do our best to meet the needs of your project.

Organization Information

Organization Name: *

Organization Name in Haiti:

If different from Organization Name.

Mission: *

Partners:

Please list any partners your organization has worked with in the past or currently works with to provide services or materials to Haiti.

Contact Information

Primary Contact

Name: *

Title:

Phone: *

Email: *

Address: *

Haiti Contact

If different from Primary Contact.

Name:

Title:

Phone:

Email:

Address:

Water Contact

If different from Primary Contact and Haiti Contact.

Name:

Title:

Phone:

Email:

Address:

Project

Project Location: *

Urban

Rural

Nearest City:

If your project location is rural, please list the nearest city/urban center.

Population Served: *

Please describe the population (for example: number of residents in the communtiy, students attending the school, patients visiting the clinic per day/month/year, children living in the orphanage, etc.) served by your project.

Additional Population Information:

Please provide any other relevant information about the population served by your project.

Project Information

Project Name: *

Please provide the name of the community, school, hospital/clinic, orphanage, or other project.

Founding Date:

Please provide the date the community, school, hospital/clinic, orphanage, or other project was founded.

History:

You may provide a brief history of the community, school, hospital/clinic, orphanage, or other project, if you wish.

Permissions:

I will email a report detailing the use of the donated materials to info@haitiwater.org within a month of completing the project.

I will email photos to info@haitiwater.org within a month of completing the project.

International Action may share information I provide through print and electronic communications, including but not limited to newsletters, email campaigns, and the International Action Website.

Please check beside the statements to indicate that you agree to the request.

Additional Information:

Please provide any additional information you would like us to have when considering your project.

By submitting this form, you accept the Mollom privacy policy.

International Action – 819 L Street, SE, Washington, DC 20003
501(c)(3) Tax-Exempt Non-Profit Organization

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