2025 Love Honduras Application

Electronic Application

The application has SIX parts (SEVEN if you are a veterinarian or apply for the Veterinary Team). All parts will need to be completed before your application will be considered. Part 1 is the application for admission onto the mission team. Upon completion of this form you will need to enter your electronic signature (typed full name). Part 2 is the Mission Expectation Form which you will need to electronically sign to agree to expectations. Part 3 is the Ministry Release From which you will need electronically sign (and have a witness signature) releasing the Episcopal Diocese of West Texas from liability. Part 4 is the travel information/preferences section. Part 5 is the submission of a copy of your veterinary license (veterinarians). Part 6 is PROOF of rabies prophylaxis vaccination or adequate titer protection. PART 7 IS SUBMITTING YOUR $300 FEE EITHER VIA THE WEBSITE LINK, OR VIA CHECK. THE LINKS ARE ON THE APPLICATION PAGE.

Questions

Please contact Kerry Green with any questions.

210-415-0165

redraider9393@gmail.com

APPLICATIONS ARE DUE BY MIDNIGHT DECEMBER 31, 2024.

To apply to attend the 2025 Vet and Public Health Mission Trip to Honduras please complete all applicable sections.

YOU MUST SUBMIT THE $300.00 TRANSPORTATION/MEAL FEE WHEN YOU APPLY.

Veterinarians MUST submit a copy of their license to Dr. Blake Peurifoy at blakensteph@gmail.com WHEN THEY SUBMIT THEIR APPLICATION.

You MUST submit rabies prophylaxis PROOF (veterinary team applicants) by April 15, 2025. Please note that Public Health Team members are NOT required to be vaccinated against rabies.

YOU MUST SUBMIT THE $300.00 PARTIAL IN COUNTRY TRANSPORTATION/ MEAL FEE WHEN YOU APPLY.

This is a non-refundable fee that we use to arrange/secure transportation/meals. If for some reason you are not selected to attend the Mission trip, we will refund your application fee. Otherwise, the fee is NON-REFUNDABLE.

CONTACT INFORMATION

PLEASE fill in with a email address and phone number that you CHECK FREQUENTLY! It is important that you RESPOND to messages from trip leaders regarding the Honduras Mission Trip when requested. We typically start sending information in January and emails become more frequent as we get closer to the departure date in May.

Name*

First NameLast Name

E-mail*

Cellular Number *

Area CodePhone Number

Home Number

Area CodePhone Number

Permanent Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Emergency Contact Name*

Emergency Contact Address*

Emergency Contact Phone Number*

Area CodePhone Number

Your Gender*

MaleFemaleOther

Have you ever PARTICIPATED in THIS Mission?

YESNO

If this is your first time applying for this mission, who referred you?*

Rooming Information - READ CAREFULLY

We will attempt to accommodate your rooming request, but we may need to assign you a roommate(s). If you have a roommate preference you AND the prospective roommate(s) should list each other. You may contact Leigh Walker (drwalker@coatsvet.com) with rooming questions.

We can accommodate up to 4 people in a room. Remember that there is 1 bathroom per room.

If you would like to room alone, mark ALONE.

If you would like a roommate or roommates, mark ROOMMATE

If you do not have a specific roommate request, specify NONE

Marital Status*

SingleMarried

Rooming Preference*

RoommateAloneNone

Name of preferred roommate(s). We will make every attempt to accommodate requests, but rooming choices are not guaranteed. It is possible that you may end up rooming with up to 3 other people. Note that roommates assigned will be same-gender unless otherwise requested.

Which team are you applying to be a part of?*

Veterinary TeamPublic Health/Vision TeamI would be happy to join either team

Previous Overseas or Cross-Cultural Experience*

Other Training or Skills that would apply*

Spanish-speaking skills. Please do NOT overestimate your ability. It is essential that we know who can act as a translator for our teams! Note that the ability to speak or translate is not essential for the trip.*

Native Speaker (i.e. can translate English to Spanish and Spanish to English in conversation)Fluent (Spanish is not your primary language, but you can translate English to Spanish and Spanish to English in most cases)College or High School Spanish (you can understand some Spanish, but may have difficulty translating)College or High School or Cultural Experience with Spanish (you can understand and/or speak a few phrases, but translating most conversation is beyond your ability)You can say taco, enchilada and hola..... but that's about it.None

Do you have any physical challenges or health problems that may affect your ability to work in primitive, frequently stressful conditions, with limited access to health care (please answer y/n and explain)? Is there anything else you’d like to share about your desire to do mission work?*

Are you a Veterinarian?

YesNo

Are you a Veterinary Student?

YesNo

If Student, Grad Year

Are you a licensed Veterinary Technician?

YesNo

Veterinary Teams typically split into small and large animal teams. Please select which best applies to you:

I'm applying for the Vision TeamEither small or large animal, I'm very flexiblePrefer Large, but willing to work where neededPrefer Small, but willing to work where needed

Summarize any special skills or qualifications you may have that would enhance your ministry work

Veterinary Team Applicants Additional Information:
All veterinarians must send a copy of their state license renewal certificate or their diploma if they are new graduates and all veterinary team members must send a copy of proof of preexposure rabies prophylaxis or protective antibody titer to:

Blake Peurifoy, DVM
blakensteph@gmail.com

704-787-2384

Direct Questions To:

Kerry Green
redraider9393@gmail.com

210-415-0165

-----

I confirm that all of the information given is true and accurate. I hereby authorize the release of all information relevant to the mission. The Episcopal Diocese of West Texas is not responsible for any illnesses, injury, or lost/stolen property while I am on this trip. I understand that all workers on veterinary teams must provide proof of appropriate pre-exposure rabies vaccinations or proof of protective rabies antibody levels.

Signature (Type Name)*

Signature date*

We are excited that you have considered being part of the Veterinary and Public Health Ministry to Honduras. For more than 30 years, the ministry has been working with and serving the people and animals of Honduras. The people of past missions have set a high standard of service that we know you will want to continue. If you would like work in a specific area such as small animal, large animal, or public health, we will make every effort to assign you where requested, but we do reserve the right to assign you to a different working team based upon the needs of the ministry. We cannot promise to place people with specific friends or family. We strive to place people according to work experience, Spanish speaking skills and level of expertise according to the needs of the ministry. We hope that you will honor the time and energy that we spend finding a place for you and expect you to work with the team we have chosen for you. We will also assign hotel rooms.

We are in Honduras to serve others. If you keep that foremost in your mind, we are absolutely certain that you will return with many memorable experiences.

“God is a helper; it is the Lord who sustains my life.” Psalm 54:4

I agree to the above ministry expectations.

Signature (type name)*

Signature Date*

The Episcopal Diocese of West Texas

Short Term Mission Trip Release Form

Destination: Honduras

Trip Dates: May 17-23, 2025

The Episcopal Diocese of West Texas Release and Hold Harmless Agreement

Whereby, I, named in the above application, am about to travel with representatives of The Episcopal Diocese of West Texas, to any country in which The Episcopal Diocese of West Texas has or may be planning to have a ministry work, to tour and or work on projects in said countries, and whereas I am doing so entirely upon my own initiative, risk and responsibility, and in consideration of The Episcopal Diocese of West Texas accepting me as a constituent trip member and undertaking to arrange matters of transportation, lodging, food, and other travel details of permitting me to view, tour and/or work on Episcopal Diocese of West Texas projects, office and geographical areas in need of assistance, I hereby, for myself, my heirs, executors and assignees, release and forever discharge The Episcopal Diocese of West Texas and any of its affiliates, or subsidiaries, directors, employees, and volunteers, acting officially and otherwise and any person acting as a trip coordinator(s) on behalf of The Episcopal Diocese of West Texas, from any and all claims, demands, actions, or causes of action on account of my death, or any injury to me or my personal property, which may occur from any cause, including negligence of any type, during said trip.

Therefore, neither The Episcopal Diocese of West Texas, nor any of its affiliates or subsidiaries, directors, officers, agents, employees, or volunteers, shall be or become liable or responsible for any loss, injury or damage to person, property or otherwise in connection with, by the way of example but not by way of limitation, accommodations, transportation or other services, resulting directly or indirectly from acts of God, dangers, incident to the sea, air, land, fire, breakdown, misuses in machinery or equipment, acts of government or other authorities, de jure or de facto, wars, whether declared or not, hostilities, civil disturbances, strikes, riots, thefts, pilferage, epidemics, changes in itinerary or schedules or for any loss or damage resulting from insufficient or improperly issued passports, visas, or other documents or from delay, and that neither The Episcopal Diocese of West Texas, nor of its affiliates or subsidiaries, directors, officers, agents, employees, and volunteers shall be or become liable or responsible for any additional expenses or liability sustained or incurred by the tour member as a result of any of the foregoing causes or any unnamed cause.This Agreement shall be governed by the laws of the State of Texas.

By executing this agreement, I acknowledge that I have read and accepted all its terms and conditions.

Signature (type name)*

Signature Date*

Witness Signature (type name)*

Witness Signature Date*

Enter the message as it's shown*

Full Name as it appears on your passport

First NameMiddle NameLast Name

Passport Number

Birth date

Date

Passport Issue Date

Date

Passport Expiration Date (must be no earlier than November 25, 2025)

Date

Global Entry Number (if available)

United Frequent Flyer Number (if available)

Preferred Departure City

If other city selected please specify below

Remember that this form DOES NOT make travel reservations for you. REMEMBER TO WAIT to make reservations or contact the travel agent until after you hear if you have been confirmed as a participant.

I have emailed or submitted a copy of my veterinary license to Dr. Blake Peurifoy at blakensteph@gmail.com

I have been previously vaccinated against rabies

If you have been previously vaccinated against rabies, what year?

For those within driving distance of Seguin, TX there is an opportunity for rabies vaccination in the spring. If you are interested, please notify Dr. Bill Campaigne (see below). There is a charge for the vaccination(s) - generally around $120 for the initial series. Please note that Public Health Team members are NOT required to obtain rabies vaccination to participate in the Mission Trip.

Please email Dr. Campaigne NOW at wcc711@hotmail.com if you wish to receive your rabies vaccination(s) in Seguin in Spring 2025.

Submit your proof of vaccination or protective titer to:

Blake Peurifoy, DVM
blakensteph@gmail.com

I plan to be vaccinated or obtain a current titer PRIOR to the May 2025 trip. YOU WILL NOT BE ALLOWED ON A VETERINARY TEAM WITHOUT PROOF OF EITHER A RABIES VACCINE (Given between March 2024 - April 2025) OR Proof of a protective rabies titer (Obtained between January 2025 - March 2025).

PART 7

Go to the website (HondurasVetMission.org) and PAY your $300 fee. Select the tab that says donate and follow the instructions.

2025 Mission Trip Application

Part 1: Application

Part 2: Ministry Expectation Form

Part 3: Ministry Release Form

Part 4: Travel Information/Preferences

Parts 5&6: Veterinary Team Extras