Santa Barbara, Honduras
Full Name (Same as appears on your passport):
Passport# ____________________________________Expiration Date: ___________________________
Phone: (H) __________________ (W) ___________________(C) _______________________________
Occupation: ______________________________E-mail: ______________________________________
City: ___________________________________State: ______________Zip: _____________________
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:_____________________
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 (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:
Attn: Chelsey Moore
603 Munger, Suite 100-218
Dallas, TX 75202