Medical Mission Team Application

If you are requesting supplies from MedShare to carry as extra baggage on an overseas flight, or if you would like to receive a domestic shipment of less than a container load for use overseas, please fill out the application below.

Today's Date

MonthDayYear

1. Your Destination

Name of Facility*

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

2. Primary Contact

This should be the U.S. contact person responsible for the trip.

Name*

Title*

Organization or Facility*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number*

Area CodePhone Number

Fax

Area CodePhone Number

E-mail*

Which MedShare facility is closest to you?*

3. Medical Professional Responsible for the Supplies Received

Medical professional*

There is a medical professional and her/his information followsThere is a medical professional and s/he is the same as the primary contactThere is NO medical professional associated with this trip

Name of Medical Professional

Title

Organization or Facility

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone

Fax

E-mail

4. Trip Details

Departure Date*

MonthDayYear

Return Date*

MonthDayYear

Date Supplies Needed *

MonthDayYear

Do you need 100 lbs or more of medical supplies?*

YesNo

Approximately what volume of supplies would you like to request from MedShare? (You can express this figure as number of suitcase loads, number of boxes, maximum weight, etc...)*

Briefly describe the nature of your trip:

Type of organization to which you belong (if applicable) **

Upload 501(c)3 documentation here:

Upload a File

If "Other" please specify:

What are the major health problems to be treated during this trip?*

What are the estimated number of patients to be treated during this trip?

Please describe the population and environment of the area with regard to livelihood, language, cultural history, etc...

5. Feedback Information

Have you or other group members received assistance from MedShare before?

If yes, when?

How did you hear about MedShare?

6. Recipient Agreement

Accept Recipient Agreement In Order to Submit*

I guarantee that the supplies I receive as donations from MedShare International, Inc. will be delivered to the organization described above to benefit patients in need. I understand that these supplies are donated, have no commercial value, and therefore I will not sell or exchange these items for profit. I further attest that I have read and agree to receive donated items from MedShare according to the stipulations below.

The medical supplies, equipment, materials and other items available from MedShare are items that would have been discarded or otherwise disposed of by hospitals or health care providers in the United States. These Materials are being made available strictly on an as is basis for humanitarian use in circumstances in which sufficient alternative sources of such resources are not available. The recipient organization recognizes that MedShare and the donor facilities do not make any representations or warranties, either express or implied, as to the condition of the Materials, and further recognizes that MedShare and the donor facilities make no representations or warranties, express or implied, that the Materials are fit, appropriate, free from defects, sterile, pure, operable, or otherwise suitable for any intended purpose. The recipient organization accepts the Materials as is, with all faults, and acknowledges that the inspection for any defects and the safe operation of said Materials is solely the responsibility of the recipient organization. Each recipient organization, recipient facility, and responsible manager of such entities assumes full responsibility for making an independent determination of the appropriateness of the Materials (or any part thereof) before using them, and for discarding any Materials which are not appropriate for use. Under no circumstances shall MedShare, the manufacturer or distributor of the Materials, or any United States hospital or health care provider that ever owned or used the donated equipment, be liable to recipient organization or anyone for any direct, special, indirect, incidental, or consequential loss or damage resulting from the Materials or their use. To the maximum extent permitted by law, the recipient organization fully accepts and assumes all risks and all responsibility for losses, costs, and damages that the recipient organization, its agents, representatives, members, directors, officers, employees, agents, contractors, patients, and transferees may incur as a result of the Materials or their use, including without limitation personal injuries, illness, damage, loss to property, and death.

MedShare and the recipient organization recognize that this agreement shall release MedShare and the donor facilities from any and all liability for personal injury and/or any other type of injury arising from the use of the Materials. The recipient organization acknowledges that the consideration for this release and indemnification is the donation of the Materials themselves. By making an application for the receipt of such Materials and by accepting such Materials, the recipient organization, to the maximum extent permitted by law, fully releases, acquits, and forever discharges MedShare, the donor facilities, and each and every past and present subsidiary, affiliate, officer, director, agent, servant, employee, trustee, and representative of MedShare and the donor facilities from any and all loss, damages, claims, causes of action, suits, debts, liens, obligations, liabilities, demands, costs and expenses of any kind, character, or nature whatsoever, known or unknown, fixed or contingent, which might arise from or be related or associated in any way with the Materials or their use, including but not limited to any injury, illness, disease, property damage, death, or loss of any nature suffered or sustained in connection with the use or possession of the Materials. To the maximum extent permitted by law, the recipient organization also agrees to indemnify, save, and hold the Released Persons and Entities harmless for any loss, damages, claims, causes of action, suits, debts, liens, obligations, liabilities, demands, costs and expenses (including attorneys fees) of any kind, character, or nature whatsoever, known or unknown, fixed or contingent, which may be incurred arising out of or related to the use or possession of the Materials, regardless of the nature or the extent of the injury, illness, disease, property damage, death, or loss, and regardless of whether it results from the negligence of the Users or of the Released Persons and Entities.