Timmy Global Health Medical Service Trip: Registration Form for Medical Professionals
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 leia@timmyglobalhealth.org no later than six 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)
For anyone purchasing an individual flight, we strongly encourage you to purchase your own flight insurance (at the point of purchase).
4. Trip Payment(s)

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

As a trip volunteer, please notify our administrative team if you plan to travel to an Ebola affected country with widespread transmission between now and your Timmy medical service trip. Persons who have traveled to an Ebola affected country within 30 days of a Timmy Medical Service trip may not travel with our team. Please notify Anne Krieger as soon as possible at anne.krieger@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.


Please direct all questions and concerns to the Service Trip Coordinator, Anne Krieger at:

Timmy Global Health
Attn: Anne Krieger
I️22 E. 22nd St.
Indianapolis, IN 46202

Tel: 317-556-5388
Fax: 317-920-1821
Email: anne.krieger@timmyglobalhealth.org
Email address *
Are you a returning Timmy volunteer? *
How did you first hear about Timmy? *
Required
Trip Destination *
Please select the location you'll be serving for the week NOT the city you will be flying to.
What month are you traveling? *
Travel Group/Chapter *
Please select the chapter that is associated with this trip (if unsure, please leave blank or select 'N/A')
If you selected 'Other', please list the associated chapter:
First Name *
As it appears on your passport
Middle Name
As it appears on your passport
Last Name *
As it appears on your passport
Preferred Name or Nickname
If applicable
Gender *
Date of Birth *
mm/dd/yyy
What is your t-shirt size? *
Passport Number
Please note that your passport must not expire within 6.5 months of your trip date. US citizens are not required to obtain a visa for travel to Ecuador, Guatemala, or the Dominican Republic. For non-US citizens, please confirm with the embassy/consulate of the country you will be visiting to determine if a visa is required.
Country of Citizenship *
Current Address *
Current City *
Current State *
Current Zip Code *
Permanent Address
If different from current address.
Permanent City
If different from current address.
Permanent State
If different from current address.
Permanent Zip Code
If different from current address.
Cell Phone *
Please include area code.
Home Phone
Please include area code.
Preferred Email Address *
Trip Role: *
Please select one.
What is your medical specialty? *
If applicable
Are you willing to see patients outside of your specialty?
If applicable
Clear selection
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 medical Spanish interpreter in our clinics? *
Allergies
Dietary Restrictions
Current Medication(s)
Medical Condition Information
*Selecting “yes” to the following does not preclude you from joining the trip. It is important to share exhaustively any active medical condition that you will need or will possibly need to address while on brigade. This will allow Timmy to be able to best support you medically.

If you selected yes.....
*Keep in mind that our brigades require that you be able to walk decent distances, or handle intense heat or altitudes (depending on the site). Please let us know if you have any concerns meeting these requirements. We can work with you to match you with a trip that best suits your abilities.
Do you have a medical condition Timmy should be aware of? *
If you answered "yes" to the above question, please elaborate.
Physician Name
Used only in case of an emergency.
Physician Phone Number
Used only in case of an emergency.
Emergency Contact Name *
Emergency Contact Cell Phone *
Emergency Contact Other Phone
Work or home
Emergency Contact Email Address *
Used for notification of safe arrival.
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 *
Date *
mm/dd/yyyy
Please check one: *
Medical Information Release
I hereby authorize the use or disclosure of my individually identifiable health information for the limited purposes described below. I understand that if the organization or persons authorized to receive the information is not a health plan or health care provider, the released information may be redisclosed and no longer protected by privacy regulations.


Specific description of information to be used or disclosed (including date(s)):
Any and all medical and non-medical records, physician’s records, surgeons’ records, reports, x-rays, CAT scans, MRIs, tests, photographs, notes, disability ratings, laboratory reports, discharge summaries, progress notes, consultations, prescriptions, physicals and histories, nurses’ notes, correspondence, prescription records, medication records, orders for medication, therapists’ notes, insurance records, consent for treatment, statements of account, bills, invoices, or any other papers concerning any investigation, treatment, examination, periods or stays of hospitalization, confinement, diagnosis, testing, prognosis, or other information pertaining to or concerning my past or present physical, mental, emotional, or any other condition.


Reason for use or disclosure of information:
On rare occasions, urgent and emergent medical situations may arise. In these instances, Timmy Global Health staff and volunteers are requested by the volunteer’s health care provider(s), family member(s) or educational institution to disclose information regarding the volunteer’s condition.

This release is made for the limited purpose of allowing the staff and volunteers of Timmy Global Health to disclose a volunteer’s health information to provide the volunteer with assistance, should the need arise.
In agreeing to each of the following statements: *
Required
Name *
Date *
MM
/
DD
/
YYYY
Cancellation Policy
Trip registration and deposits are due 4 months (120 days) prior to the trip’s departure. If a trip participant cancels prior to the registration deadline, 100% of what they have paid will be reimbursed. Should a trip participant cancel anytime after this deadline their deposit becomes non-refundable and remaining trip costs paid will be refunded based on the value the participant has paid at the time of cancellation and in accordance to the below schedule.
Should a trip participant cancel 60-119 days within the trip's departure, and they were confirmed on the group flight, they are responsible for finding an alternate to take their group flight seat and covering the cost of this change fee (if applicable). Timmy will refund 100% of remaining on-the ground costs (deposit is non-refundable).

Should a trip participant cancel 30-59 days before the trip’s departure, the above statute for group flight responsibility still stands. Timmy will refund 50% of their on-the ground costs (deposit and flight costs, if not transferred, are non-refundable). Participant may receive a credit directly from the airline dependent upon the contracted agreement with the airline and the date of cancellation.

Should a trip participant cancel 15-29 days before the trip’s departure the above statute for group flight responsibility still stands. Timmy will refund 25% of the participant’s on-the-ground costs (deposit and flight costs, if not transferred, are non-refundable)

Should a trip participant cancel less than 14 days before the trip’s departure, barring an approved extenuating circumstance, they are not approved for any credit or refund of trip costs.
Please check: *
Name: *
Date: *
MM
/
DD
/
YYYY
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 *
Date *
mm/dd/yyyy
Please check: *
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 *
Date *
mm/dd/yyyy
Please check: *
Volunteer Health and Safety Agreement
I understand that, as a volunteer on a Timmy Global Health medical service trip, my health is my personal responsibility.

In order to protect my health, I understand that I am expected to:

A. Obtain the recommended medicines and vaccines for the country/location I am visiting. Timmy Global Health does NOT indicate which medicines and vaccines are required for volunteers; however, we strongly recommend that, prior to their trip, travelers read carefully the Centers for Disease Control (CDC) page that corresponds to the country they are visiting and see a travel medicine specialist in order to understand the preventive health measures they should take.

Please see the following CDC sites for traveling to:

Dominican Republic: http://wwwnc.cdc.gov/travel/destinations/traveler/none/dominican-republic?s_cid=ncezid-dgmq-travel-single-001

Ecuador: http://wwwnc.cdc.gov/travel/destinations/traveler/none/ecuador?s_cid=ncezid-dgmq-travel-single-001

Guatemala: http://wwwnc.cdc.gov/travel/destinations/traveler/none/guatemala?s_cid=ncezid-dgmq-travel-single-001

B. Be aware of the risks that mosquito bites carry, especially in countries currently affected by the Zika Virus, and do my best to prevent bites by bringing personal mosquito repellent and clothing/shoes that will cover my skin. Mosquito repellent with DEET is strongly recommended. For more information about traveling to countries affected by the Zika Virus, please visit the following CDC site: http://wwwnc.cdc.gov/travel/page/zika-travel-information

C. Conduct myself responsibly and safely during the medical service trip. To this end, Timmy Global Health requires that participants adhere to the following:

DO NOT touch or play with stray animals or farm animals. Feral dogs are especially common and can carry diseases that are easily transferred.

DO NOT eat food from places that have not been vetted by Timmy Global Health, especially "street food" and other non-commercial food vendors.

DO NOT drink water from the tap at any time, and avoid its use in brushing teeth.

D. Respect the rule that only physicians, dentists, physician assistants, nurse practitioners, nurses and medical/dental students (with direct one-to-one supervision) may use sharps. Sharps include but are not limited to: needles, lancets, sutures and scalpels. I understand Timmy's strict policy that NO other health care providers, undergraduate students or other volunteers are allowed to handle sharps at any point on a Timmy trip.
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