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Travel Application

NOMADIC WELLNESS

Travel Application

Santa Barbara, Honduras

Personal Information

Full Name (Same as appears on your passport):

___________________________________________

Passport# ____________________________________Expiration Date: ___________________________

Phone: (H) __________________ (W) ___________________(C) _______________________________

Occupation: ______________________________E-mail: ______________________________________

Address: ______________________________________________________________________________

City: ___________________________________State: ­­­­­­­­­­­______________Zip: ­­­­­­­­­­­­ _____________________

Medical Information

DOB: _________Allergies: _______________________MEDICAL CONDITION: __________________

Any medications we should know about? (i.e., insulin, blood pressure meds, etc.) Dosage/Regimen?

_____________________________________________________________________________________

PRIMARY CARE PHYSICIAN: _________________________ PHONE: ________________________

MEDICAL INS. CO: ______________________POLICY # ________________PHONE:_____________

NAME OF POLICY HOLDER:  ________________________ MEMBER ID______________________

Emergency Contact Information

Name: ______________________ Relationship: __________________ Phone: _____________________

Name: ______________________ Relationship: __________________ Phone:_____________________

INTERESTS/SKILLS

For Physicians: What is your specialty? ___________________________________________________

For Nurses: What is your area of expertise?

□  CRNA □  PACU     □ Scrub      □ Pre-OP   □ Circulator    □ Medical

For Everyone: I speak Spanish   □ None   □ A little   □ Well    □ Fluently

 

On which trip are you planning to travel?

□ Spring   □ Fall   □ Other   □  DATES:  ______________________________________________

I would like to volunteer as a:

□ Scribe   □  General helper  □  OR Needs Assessor  □ Interpreter    □ Construction

SPECIAL SKILLS OR GIFTS: ____________________________________________________________________________________

Your Delta Airlines Frequent Flier Number (if applicable):_______________________________

AGREEMENT, PERMISSION FOR TREATMENT, RELEASE FROM LIABILITY

I understand that teamwork and trust are essential to any successful mission experience.  A commitment to participate in this mission includes a willingness to be a part of the team, abide by the guidelines that any community requires, and to be a positive contributor to the group. I agree to refrain from any activities while on the mission trip that are considered inappropriate by our hosts or The Hope Chest for Women (alcohol, tobacco, swearing, inappropriate clothing/actions, etc.)

The information contained in my medical history is correct and complete to the best of my knowledge. I hereby give permission to Nomadic Wellness to administer prescribed medicines, and to seek emergency medical treatment if needed. I agree to the release of any records necessary for insurance purposes. I give permission to Nomadic Wellness to arrange necessary health-related transportation for me. If necessary, a copy of this form may be used by qualified health professionals in the administration of treatment.

I am aware of the potential risks and dangers in traveling within this country and to/in other countries. As a participant in this mission venture to Honduras, I release Nomadic Wellness, its employees, members and officers, and any affiliates of all claims and causes of action for damages or other relief. I assume full responsibility for all travel and mission-related risks and my own actions while on this trip to Honduras.

Signed: _____________________________________________Date­­­­­­­: _____________________

Please return application with deposit to:

Nomadic Wellness

Attn: Chelsey Moore

603 Munger, Suite 100-218

Dallas, TX 75202

https://www.gofundme.com/f/nomadicwellness

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