Timmy Global Health Medical Professional Registration Form
Thanks so much for choosing to be a part of an upcoming medical service trip with Timmy Global Health!

Please only complete this application once you are ready to confirm your participation on an upcoming Timmy trip.

In order to confirm your participation on an upcoming Timmy medical service trip, participants must complete this application and turn in the following additional items to the Timmy Medical Service Trip Coordinator at aleman@timmyglobalhealth.org no later than 6-weeks prior to your trip departure date:

1. Passport Copy
2. Professional License and Diploma Copy
3. Flight Itinerary - (If not flying on a Timmy group flight)
4. Trip Payment(s)

Failure to provide the requested documentation may result in your inability to travel on the Medical Service Trip.

Please direct all questions and concerns to registration@timmyglobalhealth.org.

Note: Participants for Timmy medical service trips are selected on a first come – first served basis. Timmy Global Health reserves the right to refuse participation based on the needs of the team. Timmy Global Health recruits and selects participants without regard to race, color, ethnicity, national origin, religion, veteran status, gender, sexual orientation, and physical or mental disability.

Trip Destination *
Please select the location you'll be serving for the week NOT the city you will be flying to
Trip Dates *
Your answer
Travel Group/Chapter *
Please list the TGH student or university chapter you'll be traveling with
Your answer
First Name *
As it appears on your passport
Your answer
Middle Name
As it appears on your passport
Your answer
Last Name *
As it appears on your passport
Your answer
Preferred Name or Nickname
if applicable
Your answer
Gender *
Date of Birth *
mm/dd/yyy
Your answer
What is your t-shirt size? *
How did you first hear about Timmy? *
Required
Passport Number
*please note your passport must not expire within 6.5 months of your trip
Your answer
Country of Citizenship
Your answer
Current Address
Your answer
Current City
Your answer
Current State
Your answer
Current Zip Code
Your answer
Permanent Address
If different from current address.
Your answer
Permanent City
If different from current address.
Your answer
Permanent State
If different from current address.
Your answer
Permanent Zip Code
If different from current address.
Your answer
Cell Phone
Please include area code.
Your answer
Home Phone
Please include area code.
Your answer
Preferred Email Address *
Your answer
Trip Role: *
Please select one.
What is your medical specialty? *
if applicable
Your answer
Are you willing to see patients outside of your specialty? *
if applicable
If no, please indicate the target population you intend to see:
Your answer
Spanish Speaking Ability *
Please characterize your Spanish-speaking abilities by checking one of the following boxes (if applicable - Nigeria program volunteers need NOT complete the Spanish questionnaire).
Are you comfortable serving as a Spanish interpreter in our clinics? *
Allergies
Your answer
Dietary Restrictions
Your answer
Current Medication(s)
Your answer
Do you have a medical condition Timmy should be aware of and/or a condition that places you at risk for participating fully in a Timmy Medical Service Trip? *
If you answered "yes" to the above question, please elaborate.
Your answer
Physician Name
Used only in case of an emergency.
Your answer
Physician Phone Number
Used only in case of an emergency.
Your answer
Emergency Contact Name *
Your answer
Emergency Contact Cell Phone *
Your answer
Emergency Contact Other Phone
work or home
Your answer
Emergency Contact Email Address *
Used for notification of safe arrival.
Your answer
Waiver, Release and Indemnification
Participants are strongly encouraged to consult the State Department Consular Information Sheets and Travel Warnings at http://travel.state.gov/travel_warnings.html, the Centers for Disease Control (CDC) at http://www.cdc.gov and their own medical and legal advisors with regard to their destination country and risks prior to signing this agreement.

1. THE UNDERSIGNED PARTICIPANT, AND HIS OR HER PARENT OR LEGAL GUARDIAN, IF THE PARTICIPANT IS UNDER THE AGE OF EIGHTEEN (18) YEARS, (“PARTICIPANT”), IN CONSIDERATION OF PERMISSION TO PARTICIPATE IN THE TIMMY GLOBAL HEALTH, INC. (“TIMMY”) SPONSORED PROGRAM (“PROGRAM”) DOES HEREBY EXECUTE THIS WAIVER, RELEASE AND INDEMNIFICATION AGREEMENT (“AGREEMENT”). FURTHER, PARTICIPANT ACKNOWLEDGES THAT S/HE HAS THE RIGHT TO HAVE THE AGREEMENT REVIEWED BY ANY ADVISORS INCLUDING AN ATTORNEY PRIOR TO SIGNING IT. PARTICIPANT STATES THAT S/HE UNDERSTANDS THAT CERTAIN RISKS ARE INHERENT IN FOREIGN TRAVEL AND THAT S/HE FULLY ACCEPTS THOSE RISKS. THESE RISKS MAY INCLUDE, BUT ARE NOT LIMITED TO WAR, QUARANTINE, CIVIL UNREST, PUBLIC HEALTH RISKS, CRIMINAL ACTIVITY, TERRORISM, EXPOSURE TO COMMUNICABLE DISEASES, ILL EFFECTS OF UNFAMILIAR FOOD AND WATER, INCIDENTS RELATED TO GROUND, AIR, OR WATER TRANSPORTATION, ADVERSE WEATHER CONDITIONS, ACCIDENT, INJURIES OR DAMAGE TO PROPERTYAND OTHER PHYSICAL, MENTAL, FINANCIAL AND EMOTIONAL INJURY.

2. PARTICIPANT FULLY UNDERSTANDS THE RISKS ASSOCIATED WITH FOREIGN TRAVEL AND WITH PARTICIPATION IN THE PROGRAM AND AGREES TO ASSUME ALL RISKS OF PARTICIPATION IN THE PROGRAM, INCLUDING THE RISK OF CATASTROPHIC INJURY OR DEATH.

3. PARTICIPANT HIM/HERSELF AND ON BEHALF OF HIS/HER HEIRS, SUCCESSORS, ASSIGNS AND PERSONAL REPRESENTATIVES AGREES TO INDEMNIFY, HOLD HARMLESS, RELEASE AND FOREVER DISCHARGE TIMMY GLOBAL HEALTH, INC. ITS BOARD OF DIRECTORS, EMPLOYEES, AGENTS, AND COOPERATING INSTITUTIONS AND THEIR EMPLOYEES AND AGENTS FROM ANY AND ALL CLAIMS AND EXPENSES INCLUDING BUT NOT LIMITED TO THOSE ARISING FROM THE PARTIE’S OWN NEGLIGENCE, INCLUDING, BUT NOT LIMITED TO REASONABLE ATTORNEY’S FEES, FOR ANY INJURY, LOSS, OR DAMAGE TO PERSON OR PROPERTY, INCLUDING CATASTROPHIC INJURY OR DEATH RELATED TO THE PROGRAM OR EXPERIENCED BY THE PARTICIPANT INCLUDING THOSE RELATED TO TRAVEL TO AND FROM THE PROGRAM SITE.

4. PARTICIPANT AND TIMMY AGREE THAT THE INTERPRETATION AND PERFORMANCE OF THIS AGREEMENT SHALL BE CONSTRUED IN ACCORDANCE WITH THE LAWS OF THE STATE OF INDIANA, AND ANY ISSUES, MATTERS OR CONTROVERSIES ARISING OUT OF THIS AGREEMENT SHALL BE RESOLVED PURSUANT TO THE LAWS OF THE STATE OF INDIANA. PARTICIPANT AND TIMMY AGREE THAT EITHER PARTY MAY ELECT TO HAVE ANY DISPUTE ARISING BETWEEN THE PARTIES FOR AN AMOUNT IN CONTROVERSY OF OVER $6,000 RESOLVED BY BINDING ARBITRATION. ANY COURT WITH JURISDICTION OVER THE PARTIES MAY ENFORCE THE ARBITRATOR’S AWARD. DISPUTES ARISING BETWEEN THE PARTIES FOR LESS THAN OR EQUALING $6,000 SHALL BE LITIGATED IN SMALL CLAIMS COURT ONLY IN MARION COUNTY, INDIANA. PARTICIPANT AND TIMMY AGREE THAT PROCEEDINGS TO RESOLVE OR LITIGATE ANY DISPUTE, WHETHER IN ARBITRATION, IN COURT, OR OTHERWISE, WILL BE CONDUCTED SOLELY ON AN INDIVIDUAL BASIS AND THAT NEITHER PARTICIPANT NOR TIMMY GLOBAL HEALTH INC. WILL SEEK TO HAVE DISPUTES HEARD AS A CLASS ACTION, A REPRESENTATIVE ACTION, A COLLECTIVE ACTION, A PRIVATE ATTORNEY-GENERAL ACTION OR IN ANY PROCEEDING IN WHICH PARTICIPANT OR TIMMY GLOBAL HEALTH ACTS INC. OR PROPOSES TO ACT IN A REPRESENTATIVE CAPACITY.

Name *
Your answer
Date *
mm/dd/yyyy
Your answer
Please check one: *
Volunteer Code of Conduct
Timmy Global Health asks that all volunteers adhere to a set of approved standards that take into account: 1) Timmy’s mission to provide quality services to underserved populations; 2) Timmy’s reputation/relationship with communities and our partner organizations; and 3) the safety and security of our volunteers. These standards recognize that Timmy volunteers are seen as representatives of their university, company, organization, home country and Timmy Global Health at all times throughout their service with Timmy. Agreeing to the following code of conduct is a prerequisite to volunteering with Timmy Global Health.
In agreeing to each of the following statements... *
Required
Interaction with Teammates, Hosts, Patients and Staff
1. I will demonstrate cultural sensitivity and recognize that I am a guest in the country of service. I will be understanding and open about different cultural practices regarding pace of work, lifestyle choices, faith, and other personal, cultural, and societal practices.

2. I will work cooperatively with other volunteers, Timmy staff, and the staff of Timmy’s international partner organizations. I will be respectful of the cultural, religious, and political differences present among members of the team, and will conduct myself in a respectful, productive, responsible manner at all times.

3. I will demonstrate respect for all medical professionals (both international and local) who work alongside Timmy in our clinics and will report any significant concerns privately to Timmy staff members.

4. I will undertake all clinic assignments and professional duties diligently and to the best of my ability in line with appropriate professional standards and my personal professional capacity.

5. I understand and agree to abide by the specific instructions of Timmy staff, Timmy representatives, Timmy local staff, and Timmy contracted staff at all times during the trip. I understand that failure to do so may result in harm to persons or property, and may affect my future ability to volunteer / participate with Timmy.

6. I understand that all types of harassment (sexual, physical, or based on race, age, gender/gender identity, national origin/citizenship status, sexual orientation, disability, religion, or political beliefs) in verbal/written, physical, visual or any other form are strictly prohibited. Timmy has a zero tolerance for any such unwelcome behavior or speech that creates an intimidating, hostile, or abusive environment for any trip participant, Timmy staff, partner staff, or patient.

7. I understand that my personal behavior during Timmy medical clinics and service trips will affect the quality of the service provision and experience for the entire group, and agree to conduct myself in a manner that upholds the highest standards of servant leadership, volunteerism, and personal conduct at all times.

Alcohol/Drug Policy
8. I understand that excessive or inappropriate alcohol consumption and/or behavior that indicates inappropriate consumption of alcohol on a Timmy medical service trip is not permitted.

9. I understand that possession, purchase, or use of illicit drugs and/or behavior that indicates use of illicit drugs on a Timmy medical service trip is not permitted.

Trip Policies
10. I will abide by the trip curfew (typically no later than 10:30 p.m.) and remain in the lodge/hotel for the duration of the night.

11. I will refrain from giving any gifts or making any donations during Timmy’s medical clinics (this includes making promises of gifts or favors to any patient, international partner, or other person during the trip) that is not approved by Timmy staff. If I wish to make a donation or give a gift, I will abide by the terms specified in the Trip Booklet.

12. I understand that there are legal restrictions on taking photos of minors and publicizing those photos in the countries where Timmy Global Health operates. I agree not to take any recognizable photos of minors during Timmy Global Health medical trips without notifying Timmy staff and obtaining the expressed written consent of the person responsible for said minor.

13. I understand that during the course of my volunteer service with Timmy Global Health, I may come in contact with confidential patient information managed by Timmy's electronic medical record system, TimmyCare. I understand and agree to not share any information accessed via TimmyCare with any third party without the expressed, written consent of Timmy Global Health's Executive Director and leadership.

14. I understand that safety concerns, logistical concerns, or other circumstances may at times alter Timmy’s policies on individual free time, clinic operations, etc. I fully understand that the on the ground Timmy staff member and partner staff in charge of running Timmy trips has sole responsibility and ability to modify policies where and when he/she sees fit. I fully agree to abide by all modifications to these policies.

Name *
Your answer
Date *
mm/dd/yyyy
Your answer
Please check: *
Required
Volunteer Confidentiality Agreement
I understand and accept the following conditions and responsibilities of my volunteer position with Timmy Global Health:

I understand and accept the following conditions and responsibilities of my use of TimmyCare:

In the performance of my duties, I may gain access to or collect sensitive or confidential information and records that may be protected from disclosure (“Prote:cted Information”), including, but not limited to, patient healthcare records.
I shall treat ALL patient information accessible to or obtained by me in the performance of my duties as Protected Information, regardless of its format.
I shall use Protected Information for the sole purpose of performing my duties.
I shall not use my access permissions to enter fraudulent information into any records.
I shall immediately report any unauthorized use, duplication, or disclosure of Protected Information by myself or others.

Name *
Your answer
Date *
mm/dd/yyyy
Your answer
Please check: *
Required
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