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.

Requirements for Team Participation - Step 1 of 9

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)

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/

US Government Travel Requirements

US Government Travel Requirements (2022) The Centers for Disease Control (CDC) will require all passengers - two years or older –to show the following before boarding a flight to the United States:

- For fully vaccinated travelers: a negative COVID test taken no more than one day prior to flight departure.

- For travelers NOT fully vaccinated: a negative COVID test taken no more than one day prior to flight departure.

- Travelers who test positive, may travel with the Letter of Recovery as outlined by the CDC and the airline, and proof of a positive test within the past 90 days.

COVID TRAVEL, TESTING AND ISOLATION POLICY FOR TEAM MEMBERS

Health Caring Services and Hospital Socorro de lo Alto will follow all requirements for air travel as designated by the Honduran and United States governments.

If testing is required for air travel to the USA, those tests will be done at the hospital. Each team member will pay for all tests requested.

If a team member does not meet the requirements for air travel to the USA, they will isolate at the hospital for the period of time as defined by the CDC. Each team member will pay for all expenses incurred due to the isolation, i.e. food, lodging, transportation. When the needed isolation period is complete, as defined by the CDC, a letter of recovery for air travel will be provided by the medical staff at Hospital
Socorro do lo Alto.

If the team member requires medical care beyond what is able to be provided at Hospital Socorro de lo Alto, they will be transferred to the COVID hospital in San Pedro Sula.

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 COVID TRAVEL, TESTING, AND ISOLATION POLICY FOR TEAM MEMBERS. *

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

Vaccine Information

Health Caring Services is recommending 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.

For more information about other vaccines, see the Team Member Manual linked here: Team Member Manual (Word Document)

Honduran Government Travel Requirements

As of 10/2021, All persons entering Honduras must have proof of full vaccination, a negative COVID test taken within 72 hours of travel or a letter of recovery from COVID from a physician. For more information, talk to your team leader or visit: https://hn.usembassy.gov/covid-19-information/ or similar information site.

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

- 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 from 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

- the form can also be obtained through www.iVisa.com; the form can be applied for within 30 days of time of departure; the cost for normal processing is $20; iVisa will send you the Pre-check form you need for travel

HCS recommends www.iVisa.com for the obtaining of the Pre-check form. The official Honduran site has been known to be difficult to understand and/or the site is shut down completely. No one can enter the country without this form.

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 nine (9) weeks before departure for Honduras and are to be uploaded onto the application form as directed. If any of the documents listed are not submitted with the application or are not within the required date requirements, there will be an additional, non-refundable re-submission fee of $350.

Have all of your documents ready to upload before starting the application process to avoid this additional charge.

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

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.

Returning participants: Board Certification- current for dates of trip, 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.

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

Residents:

Medical school diploma, DEA- current for dates of trip, medical license- current for dates of trip.

All other medical professionals:

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

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.

Travel Information

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 of $40 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

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

A copy of the insurance policy will be submitted along with the team member's travel itinerary at least four (4) weeks prior to departure for Honduras. These documents are sent to your team leader/team administrator.

There are many companies that offer this coverage and it is the responsibility of the team member to make sure that the required coverage is met. Each travel insurance company has conditions that must be met in order for pre-existing medical conditions to be covered. Each team member is personally responsible to be aware of and meet those conditions.

Detailed information concerning this insurance, as well as suggestions for acquiring the insurance, are in the Team Member Manual linked here: Team Member Manual (Word Document)

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.

Team Closing Dates *

I have read and agree to the terms.

All teams have a closing date which is established in order to comply with the Honduran College 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.

Please provide us with your personal information for our records.

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.

I have read and understand all paragraphs of this consent, assumption of risk, release of liability, waiver, and indemnification. *

I understand that I am giving up substantial rights by agreeing to it. I am agreeing to this consent, assumption of risk, release of liability, waiver, and indemnification voluntarily. If I am under the age of 18 years, I have shown this to my legal guardian.

Read through the following statement which addresses the use of social media in regards to your mission trip.

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 Health Caring Services and the initial credit card fee will be deducted from the refund.

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.

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.