Application

		
		We welcome you to the ministry of Hospital Socorro de lo Alto (Help from on High) and Health Caring Services, the US 501(c)3 which provides administrative support to the Hospital.
	
		It is with much thought that this team member application has been prepared to help you experience a rewarding and fulfilling mission trip.

INTERNATIONAL TRAVEL INFORMATION - Step 1 of 6

International Travel Information

As requirements change frequently, it is incumbent for each person to be responsible for knowing what the current travel requirements are at the time of their travel.
https://travelbans.org/north-america/honduras/ or https://travel.state.gov/content/travel.html

Team Leaders will also have the pertinent information that is needed to prepare for travel, but you, the traveler, are responsible to make sure the requirements are met so as to not be turned away at the airport.

US Smart Traveler Enrollment Program (STEP)

See Team Member Manual- Team Travel- View here

Health Caring Services recommends that all team members enroll in the USA sponsored Smart Traveler Enrollment Program (STEP) to receive security messages and make it easier to locate you in an emergency: https://step.state.gov/

USA and Honduran Government Travel Requirements

See Team Member Manual- Team Travel- View here

Health Caring Services and Hospital Socorro de lo Alto will follow all requirements for air travel as mandated by the Honduran and United States governments, including testing and mandatory isolation.

If a team member does not meet the requirements for travel to Honduras or the USA, the team member is responsible for all expenses incurred, including but not limited to: team fees, travel expenses, medical expenses, all required testing, food, lodging, transportation, etc.

I have read and agree to the terms as stated above and understand that there are no exceptions to this policy.

By signing in this box, I am agreeing to abide by the above stated policy. *

Clear Signature

Signature of team member or legal guardian if the team member is under 18 years of age

Print Name

Printed name of team member or legal guardian signing for team member and legal guardian’s relationship to team member

Honduran Government Travel Requirements

See Team Member Manual Government Requirements for Travel to Honduras- View here

1) At this time, all COVID-19-related restrictions on entering Honduras are lifted. Team members are responsible for staying informed with current mandates as listed on Honduran and USA travel websites.

2) All travelers entering or exiting Honduras must have a Pre-check form. This form can be acquired 2 ways:

1. Fill out the form at the official Honduran site for free: https://prechequeo.inm.gob.hn/Register; the form cannot be applied for more than 72 hours before the time of departure; travelers will receive a confirmation email which they should print and carry with them; team leaders can obtain detailed information on how to fill out this form that can be shared with their team members.

2. Apply for the form through www.iVisa.com not more than 30 days before departure; iVisa will send you the Pre-check form you need for travel within 24-48 hours of departure; print and carry this form with you when traveling. There is a fee for this service. HCS recommends using iVisa for the obtaining of the Pre-check form.

Vaccine Information

See Team Member Manual Immunizations- View here

Health Caring Services recommends that all team members receive the COVID-19 vaccine prior to traveling to Honduras. This vaccine series should be completed at least 2 weeks prior to departure for Honduras.

Your application will not be complete until all information, payment, documents, itinerary, and travel insurance policy are submitted as requested on the application form.

The items listed below are due by the date established by the Health Caring Services Administration and communicated to team members by the team leader and are to be uploaded onto the application form as directed.

All document pictures or files sent must meet the following requirements:

In color, if the original is in color
Legible
No fingers or miscellaneous objects in the background
No glare

Passports

All the above requirements plus:

Passport laying flat
1 picture with both the signature and picture/ information pages
Passport is signed

All date-sensitive documentation must be current for dates of the mission trip you are participating on.

If any of the documents listed are not submitted with the application or are not within the required date requirements, there will be a non-refundable re-submission team fee. Have all of your documents ready to upload before starting the application process to avoid an additional charge.

ALL team members:

Passport – color picture of the signature and information pages. Passports must be valid for 6 months AFTER your DEPARTURE from Honduras.

Doctors:

1st-time participants: medical school diploma, residency certificate, Board certification- current for dates of trip, DEA- current for dates of trip, medical license- current for dates of trip, CV- current for dates of trip.

Returning participants: Board Certification- current for dates of trip, DEA- current for dates of trip, medical license- current for dates of trip, CV- current for dates of trip.

CRNAs:

1st- time participants: CRNA school diploma, license- current for dates of trip, CV- current for dates of trip.

Returning participants: license- current for dates of trip, CV- current for dates of trip.

Residents:

1st-time participants: Medical school diploma, DEA- current for dates of trip, medical license- current for dates of trip.

Returning participants: DEA- current for dates of trip, medical license- current for dates of trip.

Dentists:

1st-time participants: dental school diploma, DEA- current for dates of trip, dental license- current for dates of trip, CV- current for dates of trip.

Returning participants: DEA- current for dates of trip, dental license- current for dates of trip, CV- current for dates of trip.

All other medical professionals:

Training certificate or diploma, license- current for dates of trip.

Team Closing Dates

All teams have a closing date which is established in order to comply with the Honduran Department of Medicine regulations and make arrangements for the team at the hospital. If these dates are not observed, it will be with regret that the team member will have to be removed from the team roster, with all trip expenses incurred by team member to that point being the responsibility of the team member and not Health Caring Services. Your team closing dates will be given to you by your team leader.

Acknowledgement *

I have read all of the above information and accept responsibility for following all of the stated requirements. If I am filling out this application for a team member, I will make sure all of this information is given to the team member/ applicant.

Team Travel Information

See Team Member Manual Booking a Flight- View here

All team members are to arrive midday and depart on the dates specified by your team leader as the team arrival and departure dates. Evening arrivals are not accommodated by hospital transport. If a team member arrives or departs on a day different than the dates designated for the team, there will be an additional fee to cover the cost of the transport. In addition, itineraries that do not fall on the specified dates must be approved before the booking of that itinerary.

Travel Insurance

See Team Member Manual Travel Insurance- View here

Health Caring Services requires all team members to purchase Travel Insurance with coverage for emergency medical evacuation with a minimum of $500,000 per person.

Detailed information concerning travel insurance, as well as suggestions for acquiring the insurance, are in the Team Member Manual.

Travel & Insurance Agreement *

I have read and agree to the terms regarding the travel and insurance policy.

Team Member Manual *

I have read and agree to the terms stated in the Team Member Manual.

The Team Member Manual (Word Document) has been written to provide the team member with the information needed to help you prepare and participate on your team with the maximum benefit for your team, the patients, the hospital and you. Please print and read this manual.

Please provide us with your personal information for our records.

Name as listed on Passport *

First

Last

Preferred Name *

Email Address *

Phone Number *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

How did you come to know Christ?

Emergency Contact Information

Emergency Contact Name *

First

Last

Contact Relation *

Emergency Contact Phone Number *

Consent, Assumption of Risk, Release of Liability, Waiver, and Indemnification

I understand that all mission trips abroad carry with them significant risks. Although Health Caring Services, Inc., a Kentucky nonprofit corporation (“HCS”), has taken reasonable and prudent steps to reduce foreseeable risks, they still exist. Accordingly, in exchange for my, and my minor child(ren), if applicable, being allowed to participate in the upcoming mission trip to Hospital Socorro de lo Alto (the “Hospital”) to provide health care services to local Hondurans, coordinated by HCS and the Hospital (the “Mission Trip”), I agree, on behalf of myself and my minor child(ren) who accompanies(y) me on the Mission Trip (individually and collectively, “I,” “me,” and “my”), to be bound by each of the following:

1. Voluntary Participation

I understand and confirm that my participation in the Mission Trip is voluntary. My participation in the Mission Trip is as a servant-learner and I will adopt that attitude when interacting with my fellow team members, the people I meet during the Mission Trip and the Hospital. I will abstain from making derogatory or offensive remarks or arguments regarding people, politics, sports, religion, race or traditions. I agree to support the mission of HCS, the Hospital, and the cause of Christ on the Mission Trip. I agree to respect and follow the advice of HCS concerning attire, drinking, smoking, drugs and cultural traditions that will help me to honor the mission and integrate into the local community.

2. Identification of Risks

I understand that there are certain dangers, hazards, and risks inherent in participation in the Mission Trip, including, but not limited to, those associated with travel to and from the Hospital; inadequacies of lodging; patient care inside and outside of the Hospital; unstable political situations; different and under-developed facilities; uncertain medical, transportation, and communication infrastructure; possible acts of terrorism; and health hazards due to contaminated food and water, diseases, pests, or poor sanitation. I understand that my participation in the Mission Trip may involve risk of injury and loss, both to person and to property. I also understand that the risk of injury may include the possibility of permanent disability or death, and further may include the risk of exposure to novel coronavirus (collectively, with any mutation or variation, “COVID-19”). There may be other risks of participation in the Mission Trip, some of which may not be known or reasonably foreseeable at this time. I further understand that some of the premises, facilities, and equipment used in connection with the Mission Trip may not be owned, maintained, or controlled by HCS or the Hospital. I understand that this Consent, Assumption of Risk, Release of Liability, Waiver, and Indemnification is intended to address all of the risks of any kind associated with my participation in any aspect of the Mission Trip, including, particularly, such risks created by actions, inactions, fault, or negligence on the part of HCS, the Hospital and their respective directors, officers, employees, agents, volunteers, successors, or assigns (collectively, the “Releasees”), including, but not limited to, risks created by the following: (a) the risk of exposure to COVID-19; (b) my physical, emotional, and psychological limitations and/or discomfort; (c) the physical, emotional, and psychological limitations and/or discomfort of others; (d) the use and/or condition of premises on which various Mission Trip activities may occur; (e) the lack or inadequacy of policies, rules, or regulations with respect to the Mission Trip; (f) the failure of Releasees to foresee or protect me from actions, inactions, fault, negligence, recklessness, or intentional or criminal misconduct of other persons; (g) the inadequacy or unavailability of medical facilities, treatment, and/or professionals; or (h) the lack or inadequacy of supervision by Releasees.

3. Assumption of Risk

I assume all risks, known and unknown, foreseeable and unforeseeable, in any way connected with my participation in the Mission Trip, including (but not limited to) risks associated with exposure to COVID-19. I accept personal responsibility for any liability, injury, loss, or damage in any way connected with my participation in the Mission Trip, including (but not limited to) risks associated with exposure to COVID-19.

4. Release of Liability and Waiver

I release and hold harmless Releasees from any and all liability for and waive any and all claims for injury, loss, or damage, including attorneys’ fees, to the fullest extent permitted by law, in any way connected with my participation in the Mission Trip, even if caused in whole or in part by the negligent acts or omissions of Releasees, including (but not limited to) risks associated with exposure to COVID-19 (a “Claim”). This release and waiver does not apply to gross negligence or intentional misconduct of Releasees.

5. Indemnification

I agree to indemnify and to hold harmless Releasees from any Claim or expense, including reasonable attorneys’ fees for the legal counsel of Releasee’s choice, in any way connected with a Claim. This includes, but is not limited to, the cost of defending any Claim I, or any member of my family, might make, or that might be made on my behalf, or on behalf of any of my family members, that is released or waived by this instrument.

6. Policies and Exposure Notice

I agree to abide by all policies, rules, regulations, guidelines, and instructions of HCS, the Hospital, and the Honduran government including policies and safety measures intended to mitigate exposure to COVID-19, and to notify HCS or Mission Trip personnel immediately at any time prior to my departure or during the Mission Trip if I learn that I have, or may have been exposed to, or diagnosed with, COVID-19.

7. Consent to Medical Treatment

I authorize HCS and the Hospital to provide to me, through medical personnel of their choice, customary medical assistance, transportation, and emergency medical services should I require such assistance, transportation, or services as a result of injury or damage related to my participation in the Mission Trip. This consent does not impose a duty upon HCS or the Hospital, to provide such assistance, transportation, or services. I will assume the responsibility of all medical bills incurred as a result of such assistance, transportation or services. Additionally, should it be necessary for me to return home due to medical reasons, disciplinary action or otherwise, I will assume full responsibility for payment of all transportation costs.

8. Severability

If any provision (or portion of any provision) of this instrument is held to be invalid or unenforceable, that provision shall be enforceable in part to the fullest extent permitted by law, and such invalidity or unenforceability shall not otherwise affect any other provision of this instrument.

9. Applicable Law

In order to provide certainty in the law to be applied to the construction of this instrument, this instrument shall be governed, construed, and enforced in accordance with the law of the State of Kentucky without regard to its choice of law principles.

10. Modifications

This instrument may not be changed orally, and no modification, amendment or waiver of any provision contained in this instrument, or any future representation, promise or condition in connection with the subject matter of this instrument shall be binding upon any party hereto unless made in writing and signed by both parties.

11. Binding Effect

In the event of my death or incapacity, this instrument shall be effective and binding upon my heirs, estate, next of kin, executors, administrators, assigns and representatives and shall inure to the benefit of Releasees.

Health Caring Services (HCS) is a Christian organization as is Hospital Socorro De Lo Alto. Hondurans view alcohol consumption, cursing, smoking, and drug use as non-Christian behaviors. HCS asks you to refrain from alcohol, smoking, cursing and drug use on or off the hospital campus while working with the hospital. Please help us respect the Hondurans and protect the ministry of HCS and the hospital. *

By checking this box, I agree to abide by the lifestyle statement while I am in Honduras.

Lifestyle Consent Form

Social Media Consent Form

Health information is considered among the most sensitive and personal information that individuals possess. Just as patients must be able to trust their doctors with their lives and well-being, they should also be able to feel more than reassured that their health records are safe with the clinician. Besides caring for our patients, we must respect their dignity and privacy and protect their confidential information.

Protected Health Information:

Protected health information is the term given to health data created, received and stored.

Individually Identifiable Health Information:

Names (Full or last name and initial)

Dates (other than year) directly related to an individual

Phone Numbers

FAX numbers

Email addresses

ID Numbers

Biometric identifier (includes finger print)

Full face photographic images and any comparable images

Any other unique identifying characteristic (such as tattoos)

Clinical Photography/ video:

NO CLINICAL PHOTOGRAPHY/ VIDEO MAY BE POSTED ON SOCIAL MEDIA.

All departments of patient care are considered clinical photography/video areas.

Clinical photography/video may be used in medical education.

No patient’s identifiable health information may be on the photograph or video.

Non-Clinical Photography/video:

Non-clinical photography/video subjects refer to friends and family of patients who have accompanied them to the hospital.

Non-clinical photography/video requires verbal consent from the subjects as a courtesy to individuals being photographed.

Posting of non-clinical photos/videos to social media is acceptable if the person posting took the photos/video.

Public Photography/video:

Public photography/video refers to any photos taken in any place where people have no reasonable expectation of privacy.

Public photography/video may be uploaded to social media.

Violation of this policy is taken very seriously by the Health Caring Services Board and violations will be reviewed for appropriate discipline for the offending party.

Please check this box indicating your agreement to abide by the above statement. *

By checking this box, I agree to abide by the social media statement above.

Select a trip for payment: *

Trip Length *

One Week Mission Trip - $375.00
One and a Half Week Mission Trip - $525.00
Two Week Mission Trip - $700.00
Two and a Half Week Mission Trip - $850.00

If a refund of the team fee is requested, it must be approved by the Health Caring Services administration and the initial credit card fee will be deducted from the refund. Team fee refunds are not guaranteed.

If it is necessary to withdraw from a trip, HCS encourages team members to donate their team fee to HCS for team expenses or another person’s team fee.

Credit/Debit Card *

Card

Name on Card

Billing Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Total

$0.00

Thank you for your desire to serve on a team at Hospital Socorro de lo Alto. Our prayer at Health Caring Services for each of you is that God will richly bless your life and that you leave Honduras believing it is truly “more blessed to give than receive.” The Health Caring Services administration team.