Do you give permission for Health Justice for Peace Corps Volunteers to send this form to the Peace Corps' Post Service Medical Unit? (type "yes" here if you do) _______
What is the best way for the Peace Corps to contact you? (email, phone, address, etc) ____________________
Describe the problem you are having in a paragraph or two. The Peace Corps may ask for more, but this will give them an idea. ____________________
Thanks! We'll send this information on to the Peace Corps when we receive your response.