Medical Mission

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

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

Catholic Charities of the Diocese of Charleston

Attn: International Ministries

901 Orange Grove Road

Charleston, SC 29407

or as an e-mail attachment

rmedina@charlestondiocese.org

You need to be mentally and physically fit to participate in the mission. (For example, you will need to walk up and down stairs several times at the three-story clinic, walk up and down hills and trails with no handrails, and carry your bag pack or carry-on to board the boats through unstable docks that are missing slats.)

You must provide a VIRTUS certificate and agree to be screened by our diocese's Office of Safe Environment. In addition, the Diocese of Charleston now requires all participants to attend a VIRTUS training online. Please visit www.virtus.org. Attach the certificate to this application.

You will need a passport for international travel that will not expire for at least six months after the return date of 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." Please send a copy of your current passport to our office or attach it to this application. 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**

Guatemala changed the documentation required by foreign medical doctors participating in medical missions. Therefore, please send one copy of your current United States license to practice your profession, your diploma from the medical school (doctors ONLY), and a copy of your passport to the Diocese of Charleston (or attach it to this application).

Application

Medical Mission Trip to: *

Dates of Mission Trip

From * +

To * +

Please write your name exactly as it appears on your passport

First Name *

Middle Name

Last Name *

Street Address, Apt # *

City *

State *

Zip *

E-Mail Address *

Please email me updates of the Mission

Home or Cell Phone (area code first) *

Work Phone (area code first)

Participating in the mission as: *

Are you a health care professional? *

Yes

No

If yes, licensed as

License No.

State Licensed In

If MD, PA or NP please tell us your specialization *

If other, please describe

Do you carry malpractice insurance?

Yes

No

I have practiced in one of the above professions, but have no current license to practice.

Have you previously been on a medical mission trip? *

Yes

No

Date of Last Trip (Month, Day, Year)

Where?

How did you hear about the Diocese of Charleston Medical Mission? *

Do you have a passport? *

Yes

No

If yes, please complete the following:

What country?

Expiration Date (Month, Day, Year)

City and State of Birth *

Date of Birth (Month, Day, Year)

*

4 last digits of your Social Security Number *

If Married, Give Full Name of Spouse

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) *

Yes

No

Have you taken the VIRTUS class or similar certification?
(If you are a parish volunteer, it is possible that you are already certified) *

Yes

No

Date of class (Month, Day, Year)

Do you speak Spanish? *

Yes

No

ONLY if you answered yes, describe your fluency please:

very fluent

can converse with some difficulty

minimal fluency

References: Pastor Name *

Parish Name *

City *

Stamina

I can walk 1 mile before tiring. *

Easily

Some Difficulty

Not at All

I can walk 1 mile up/down hills before tiring. *

Easily

Some Difficulty

Not at All

Please list any physical limitations not otherwise described above.

Medical Information
You are responsible for bringing your medical information on the trip. This information includes, but is not limited to, the name of the 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 immunization. We also recommend Hepatitis A & B.

Medications
Please pack a one-week supply of all prescription and over-the-counter medicines you 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

Name *

Relationship *

Street Address *

City *

State *

Zip *

Cell Phone (area code first) *

Home Phone (area code first)

Electronic Signature

*

By checking this box I confirm that everything I have entered into this form is true and accurate.

*

By checking this box I acknowledge that my application will be submitted for review for a medical mission trip.

The reason I am interested in participating in this medical mission is... *

If able, attach copy of passport

If able, attach copy of SAFE HEAVEN certificate

If able, attach a copy of your medical school diploma.

If able, attach copy of medical license

Assumption of Risk Agreement

Assumption of Risk and Release of Liability

Name *

Full Address *

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 giving me the opportunity for me to volunteer my services for a planned mission trip to San Pedro La Laguna and surrounding villages in Guatemala.

from * +

to * +

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 short-term missions activities abroad 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 for providing and caring for my health and 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, 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

Date * +

*

By checking this box, I indicate that I have read the Assumption of Risk Agreement and agree to its terms.

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I allow email updates about the mission trip