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Ghana Health Mission
a nonprofit, tax exempt organization
giving North American professionals cross-cultural opportunities in
the Western Region of Ghana, West Africa.
APPLICATION FORM
Please download the entire form, including authorizations, releases and agreements, and return it via email to info@ghanahealthmission.orgor to lmckenry@comcast.net
Date:________________
Name (as it appears on your passport): _________________________________________
Permanent Address ________________________________________________________
_________________________________________________________________________
Permanent Phone ________________________________________________________
Local Address ____________________________________________________________
_________________________________________________________________________
Local Phone ____________________________________________________________
Email ___________________________________________________________________
Date of Birth: ______________________________
Passport Number ___________________________
Date of expiration ___________________________
If licensed, please provide information, i.e., type of license, state in which licensed, license number expiration date._______________________________________________________
__________________________________________________________________________
Describe any prior international health experiences:
Why do you want to participate? What are your expectations? What do you hope to learn and what can you contribute?
The hot and humid African environment is challenging. You will be required to work hard, work as a team, and live in very close quarters with no opportunity for privacy. How do you react to stress? Describe past experiences where you have had to be adaptive and flexible.
Health information (all information will be kept confidential)
Health insurance coverage information
___________________________________________________________________________
___________________________________________________________________________
There are limited available health resources in Ghana to treat emergent health crises of team members. Also, time changes, environmental changes, and malaria medications can adverse affect individuals with physical, emotional or mental health issues. Please list any health conditions you have, such as high blood pressure, heart disease, kidney disease, gastroenteritis, seizures, rheumatic fever, hepatitis, orthopedic injuries, asthma or bronchitis, diabetes, anxiety or depression, attention deficit disorder, or any other significant illness or injury:
Medications:
Dietary restrictions:
Person to contact in case of emergency ___________________________________________
Expectations for all participants
1. Attend all team meetings before, during and after the trip.
2. Pay all deposits and fees by the scheduled due date; otherwise, you forfeit your place on the team.
3. Have a current passport, Ghanaian visa, and all necessary immunizations.
4. Because the arrangements for travel to, from, and during the trip are intricate, everyone must travel together and no individual arrangements or alterations of dates will be made.
5. Sign all authorizations, releases and agreements offered by GHM and the sponsoring institution (if any).
6. Abide by all policies, practices, procedures, rules and regulations of GHM, team leaders, and the sponsoring institution (if any). Failure to do so could result in a participant being sent back to the U.S. before the end of the trip. The participant is solely responsible for all costs associated with early departure.
7. Any effort to provide gifts to children or adults in the community or to offer an invitation to visit the US, or to initiate an independent humanitarian program, whether made during or after the trip, must be coordinated through the team leader during the trip and through GHM after the trip.
Authorizations, Releases, and Agreements
Authorization for Medical Treatment, Release, and Verification of Insurance Coverage
In the event of sickness or injury, I hereby authorize Ghana Health Mission, Inc., through one or more leaders of the trip, to secure whatever treatment is deemed necessary, including the admission to a hospital, the administration of anesthetics, the transfusion of blood, and surgery.
I verify that I am enrolled in an adequate medical insurance program which will provide for coverage out of the United States and that I will maintain that enrollment for the entire period of the trip. I acknowledge and agree that Ghana Health Mission, Inc., its directors, officers, representatives, volunteers, agents, or employees are not liable for any medical claims or parts thereof, including those which are not covered by my medical insurance program.
__________________________________________________________________
Name of Health Coverage and Policy Number
__________________________________________
(Signed)
Date: _____________________________________
I hereby release, for my successors and assigns, Ghana Health Mission, Inc., its directors, officers, representatives, volunteers, employees and agents, from any and all claims and causes of action, including but not limited to claims or causes of action for loss of property or personal injury including death, arising, directly or indirectly, out of my participation in any activity sponsored by Ghana Health Mission, Inc or my travel in connection with such activity.
__________________________________________
(Signed)
Date: _____________________________________
Agreements
I agree to abide by all expectations, policies, practices, procedures, rules and regulations applicable to activities before, during and after the trip.
I agree that I will not use the name of Ghana Health Mission, Ghana Health Mission, Inc. or GHM unless I have express written permission (a license) to do so.
I understand that GHM coordinates efforts to improve the health and well-being of persons living in the Sekondi-Takoradi area. I agree that during the trip I will consult with the team leader before offering any gift, service or promise of support to anyone in the community. Furthermore, in the future if I desire to develop a separate relationship with members of the community, either individually or through another group such as a faith community, I will keep GHM informed of the plans and activities.
__________________________________________
(Signed)
Date: _____________________________________
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