Medical Mission

We invite you to complete an application to join the Diocese of Charleston Medical Mission. But before, please read the following statements thoroughly before applying for a mission trip:

  • All applicants should complete this form in its entirety and then click "submit."  The application will be sent securely to Deacon Gabriel Cuervo, the medical mission coordinator.  If you are unable to attach a copy of the requested documentation to this form (attachment options are at end of form), please send a copy to the following address:

 

Diocese of Charleston

Attn: International Ministries

1662 Ingram Road
Charleston, SC 29407

or as an e-mail attachment

gcuervo@catholic-doc.org 

 

  • You need to be mentally and physically fit to participate in the mission. (For example: walking up and down stairs several times at the three-story clinic; walking up and down hills and trails with no handrails; carrying your bag pack or carry-on to board the boats thru docks that are unstable and missing slats).
  • You need to provide a VIRTUS certificate, and must agree to be screened by the office of Safe Environment of our diocese. The Diocese of Charleston requires now that all participants attend a VIRTUS training and fill out the screening package from the mission's website (the basic information and the two pages where a signature is required. Do not fill out the Driving or Credit record pages).
  • You will need a passport for international travel that will not expire for at least six months after the returning date from the trip. Here is an excerpt from the U.S. State Department: "Some countries require that your passport be valid at least six months beyond the dates of your trip. Some airlines will not allow you to board if this requirement is not met."  It happened to one of our volunteers once and we do not want this to repeat. Please send a copy of your current passport to our office.  If you do not have one, you can get an application for a passport through your County Courthouse, local post office or online at: www.travel.state.gov/download_application. 

 

**For Health Care Professionals Only: Due With Application**

 

  • Please send one copy of your current United States license to practice your profession along with the copy of your passport to the Diocese of Charleston.

Application

Dates of Mission Trip
calendar
calendar
Please write your name exactly as it appears on your passport
 

Are you a health care professional? *
Do you carry malpractice insurance?
Have you previously been on a medical mission trip? *
Date of Last Trip (Month, Day, Year)
Do you have a passport? *
If yes, please complete the following:
Expiration Date (Month, Day, Year)

Date of Birth (Month, Day, Year)



Has the Diocese of Charleston run a background check on you in the last three years ?
(If you are a parish volunteer, it is possible that you are already screened) *
Have you taken the VIRTUS class or similar certification?
(If you are a parish volunteer, it is possible that you are already certified) *
Date of class (Month, Day, Year)
Do you speak Spanish? *
ONLY if you answered yes, describe your fluency please: *






Stamina
I can walk 1 mile before tiring. *
I can walk 1 mile up/down hills before tiring. *
Medical Information
You are responsible for bringing your own medical information with you on the trip.  This information includes, but is not limited to: name of physician(s), health insurance information, medical history, current medications, dietary restrictions, and allergies.

Immunizations
You are responsible for your own immunizations.  While it is not required, it is strongly recommended that you have an up-to-date tetanus immunizations.  We also recommend Hepatitis A & B.

Medications
Please pack a one week supply of all prescription and over the counter medicines that you will need.  Keep these in your carry-on bag.  Since brand names of drugs differ in other countries, it is recommended that you have the generic names of drugs listed on the bottles.



Emergency Contact Information



Electronic Signature

 *
 *





Assumption of Risk Agreement

Assumption of Risk and Release of Liability

In consideration of the Roman Catholic Diocese of Charleston and its agencies and personnel, in arranging and providing all the logistics of travel, housing, meals, etc., and for providing the opportunity for me to volunteer my services for a planned mission trip to San Pedro La Laguna and/or surrounding villages in Guatemala.
calendar
calendar
I hereby state the following:

a) That I am physically fit and have no medical condition that would prevent me from performing the volunteer services for which I am applying;

b) That I take full responsibility for obtaining all my immunizations and personally paying the costs;

c) That I am aware that there are hazards and risks to my person and property associated with the overseas short term missions activities for which I am applying. Such hazards and risks include, but are not limited to; death, disability, loss of ability to maintain earnings, loss of property, illness, disease, inadequate and /or unavailable medical services, weather conditions, trip delays, unlawful detention, terrorist acts, war, criminal acts, and wild animals;

d) That I agree to be solely responsible to provide and care for my own personal health, as well as my belongings.

NOW THEREFORE

I HEREBY ASSUME ALL OF THE RISKS set forth above, as well as any risks related thereto, which may result in injury, death, property damage, property confiscation, etc. and I agree to volunteer my services on behalf of the above mission, despite the hazards and risks set forth above.

I HEREBY RELEASE FROM ALL LIABILITY the Roman Catholic Diocese of Charleston (and its Bishops, agencies, employees, agents, and any affiliated organizations) for any and all claims for damages for personal injuries to myself and to my property or any damages resulting from delays in being returned to the United States.

I HEREBY AGREE TO HOLD HARMLESS and to indemnify and reimburse the Roman Catholic Diocese of Charleston (and its Bishops, agencies, agents, and employees and affiliated organizations) for any and all claims that are brought against the Diocese and its Bishops and agents, and for all expense (including attorney’s fees) that the Diocese may incur as a result of any claims presented against them, for any of my injuries and losses, or for any of my conduct related to said mission trip.
Electronic Signature
calendar
 *

captcha