Honduras MedWish Brigade Registration

MedWish Medical Brigade Registration

HONDURAS

Participating in a MedWish Medical Brigade is a wonderful way to give your time, talents, and compassion to those in need. We are excited to have you join us for the 2018 MedWish Brigade to Honduras!

Please complete the registration form found below to begin the process of securing your spot on the team. At the end of this form, you will have the option to pay the trip deposit. If you choose not to complete the payment through this form, your space will not be confirmed until your deposit is received by MedWish. If you choose to pay the deposit via check, please mail it to: MedWish International, 1625 E. 31st Street, Cleveland, OH 44114. Deposits must be received by May 1, 2018.

Please note that a number of spaces are reserved for medical professionals.

If you have any questions, please contact Britta Latz, Associate Executive Director, at blatz@medwish.org or 216.692.1685 x33.

Full Name (as it appears on your travel documents) *

First Name Middle Name Last Name

E-mail *

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Daytime Phone Number *

- Area Code Phone Number

Evening Phone Number *

- Area Code Phone Number

Date of Birth *

- Month - Day Year

Occupation *

Other Skills

Scrub Top/T-Shirt Size *

X-Small Small Medium Large X-Large XX-Large 3X-Large

Payment

I will make my deposit later:

I will be mailing or bringing my deposit to MedWish

Please note that all deposits must be received before May 1, 2018. Your space will not be confirmed until your completed regsitration form and deposit payment is received by MedWish. Complete your registration and deposit as soon as possible to ensure your spot on the team!

I will make my deposit now:

1 Participant Deposit (Non-Refundable) $ 1,500.00

Total $ 0.00

Terms and Conditions *

By checking the box above, I affirm that I am 18 years of age or older and that I have read, understand, and agree to abide by the following terms and conditions set forth by MedWish International. I further state that I am legally competent to sign this affirmation and release; that I understand the terms herein are contractual and not a mere recital; and that I have signed this document as my own free act. MedWish reserves the right to change, edit, and alter the following terms and conditions. In such a circumstance, participants will be notified immediately via email. I also certify that all information provided to MedWish in the above Brigade application is valid and correct to the best of my knowledge. Terms and Conditions: ● Should a participant's conduct be found to be dangerous or inappropriate during the Brigade, that participant may be asked to leave the trip or denied participation in future MedWish Brigades. Refunds will not be provided to participants that are asked to leave. ● Traveler’s health safety is the responsibility of the participant. Participants are encouraged to visit the CDC website for travel recommendations and seek the counsel of a physician or traveler's clinic before this trip. ● Upon the completion of registration, participants will receive various communications via email, phone, and mail from MedWish with information and updates on the trip. Participants are responsible for reading and listening to all materials provided by MedWish pertaining to this Brigade to ensure that they are fully prepared for the trip. ● Participation in this Brigade may present participants with opportunities for various levels of physical exertion. Each participant is responsible for determining what he/she is safely capable of doing. If a participant is uncertain if he/she is fit for international travel or the activities outlined in the Brigade description, it is his/her responsibility to consult with a physician before registering for this trip. By checking the box above, each participant certifies that he/she is fit for international travel and agrees to only act in ways that are within the limits of his/her own health and safety while on the Brigade. ● Participants are responsible for providing MedWish with any health information that will be relevant to this trip. This includes, but is not limited to, dietary needs such as food allergies so that MedWish can accommodate. If accommodation is not possible, MedWish will inform the participant immediately. ● By checking the box above, the participant authorizes and gives full permission to MedWish International for the use of the participant's name and photograph, still or video, in connection with this Brigade and consents to the use of such material or its reproduction in any manner and by any medium which MedWish deems appropriate. The participant equally authorizes and gives full permission to MedWish for the use and reproduction of any personal photos or videos that were taken on the Brigade by the participant and then provided to MedWish. ● Participants agree to follow directions and safety guidelines set forth by the Brigade leaders and local hosts and to act in a manner that is safe, both with regards to each individual participant and the group. ● Participants agree to follow the laws and regulations of the host country. ● Participants will be sensitive and respectful of local culture. ● Participants agree to represent his/herself and MedWish in an appropriate manner both in-person and through online publications during the Brigade. ● Participants are each responsible for transporting one bag of medical supplies with them to the site location of the Brigade. Each participant agrees to travel with those supplies and take them through customs in the host country. ● Participants agree to only act within the bounds of their professional training and experience while on the medical Brigade.Although non-medical participants may assist in medical services, they will not be administering medical counsel or care. ● Should a participant choose to extend the length of his/her stay in the host country, either before or after the dates of the Brigade, the participant understands that MedWish International is not liable or responsible for these supplemental arrangements. ● The participant affirms, understands, and agrees that MedWish International and the Brigade leaders are only responsible for making reservations or arrangements for: lodging, transportation, and meals during the trip. MedWish International and Brigade leaders will be held harmless for any occurrence in connection with or operation thereof, which may result in injury,death, or other damage to the participant. MedWish International and the Brigade leaders will not be held responsible for loss of or damage to any equipment, luggage, or personal property taken on the Brigade. ● The participant personally assumes all risks in connection with this Brigade and further releases MedWish International and the Brigade leaders from all claims, demands, and actions and for any harm, injury,or damage which may befall the participant while on the Brigade, including all risks in connection therewith whether foreseen and unforeseen, and further to save and hold harmless MedWish International and representatives, arising out of the participant's participation in this Brigade. ● In order to prevent disruption and assure a meaningful Brigade environment, it is MedWish International’s policy to prohibit unauthorized solicitation of participants and/or distribution of non-MedWish related materials during the Brigade. ● MedWish Brigade participants are asked NOT to give any money and/or gifts to any of the locals, children or staff of the organizations we visit. This is for the safety of the recipients and members of the MedWish team. If a participant feels compelled to give gifts or leave items such as clothes, shoes, candy, etc., he/she must consult with the MedWish Staff person in advance.

Name of legal guardian completing this form if the applicant is under 18

First Name Last Name