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GLOBAL HEALTH OUTREACH TRIP APPLICATION
I am applying for the medical mission trip to
Date Of Birth
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Address Line 2
State / Province / Region
ZIP / Postal Code
Antigua and Barbuda
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
British Indian Ocean Territory
Central African Republic
Congo, Democratic Republic of the
French Southern Territories
Heard Island and McDonald Islands
Isle of Man
Korea, Democratic People's Republic of
Korea, Republic of
Lao People's Democratic Republic
Northern Mariana Islands
Palestine, State of
Papua New Guinea
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Sao Tome and Principe
South Georgia and the South Sandwich Islands
Svalbard and Jan Mayen
Syria Arab Republic
Tanzania, the United Republic of
Trinidad and Tobago
Turks and Caicos Islands
US Minor Outlying Islands
United Arab Emirates
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
If other, enter in the box below
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How did you learn about Power of a Nickel?
What school are you attending? - Healthcare Students
Healthcare Student Educational Year?
Medical Training or Experience
Which medical school and residency did you attend? - Physicians
If you are not a healthcare provider, what is (or was) your profession?
Special Skills and/or Unique Abilities
Do you speak a language other than English? If so - how well?
Covid-19 Vaccination Status
Have partial completion
Have not received
Physical Limitations or Concerns
Name of Emergency Contact NOT TRAVELING WITH YOU
Emergency Contact Relationship to You
Emergency Contact's Phone Number
Emergency Contact's Email
PHYSICIAN EVALUATION AND TREATMENT
I agree to the physician evaluation and treatment consent.
I authorize a physician on this team to consent to any necessary examination, anesthetic, medical diagnosis, surgery, treatment and/or hospital care rendered to me and on the advice of any physician or surgeon licensed to practice medicine by the state and /or country in which they practice during the duration of the trip identified above. I attest my understanding and agreement by checking the box.
I agree to the medical treatment consent.
Volunteer and Guardian do hereby release and forever discharge Power of a Nickel, Inc. from any claim whatsoever which a rises or may hereafter arise on account of any first aid treatment or service rendered in connection with the Volunteer’s participation in mission work projects or with the decision by Power of a Nickel, Inc. or any representative or agent of to exercise the power to consent to medical or dental treatment as such power may be granted and authorized. I attest my understanding and agreement by checking the box.
ASSUMPTION OF RISK
I agree to the assumption of risk consent.
The volunteer and Guardian understand that the work projects may include activities that may be hazardous to the Volunteer and that the food, accommodations, and medical facilities may be donated to Power of a Nickel, Inc. and beyond its control. I attest my understanding and agreement by checking the box.
WAIVER & RELEASE
I agree to the waiver & release consent.
Volunteer and/or Guardian do hereby release and forever discharge and hold harmless Power of a Nickel, Inc. and it’s successors and assigns from any and all liability, claims, and demands of whatever kind of nature, either in law or in equity, which arise or may here after arise from Volunteer’s participation in mission work projects. Volunteer or Guardian may have with respect to bodily injury, personal injury, illness, death, or property damage that may result from Volunteer’s participation in mission work projects. Volunteer and Guardian also understand that Power of a Nickel, Inc. does not assume any responsibility for or obligation to provide financial assistance or other assistance including but not limited to medical, health, evacuation, or disability insurance. I attest my understanding and agreement by checking the box.
I agree to the insurance consent
INSURANCE - The Volunteer and Guardian understand that Power of a Nickel, Inc. does not carry or maintain health, medical, evacuation, cancellation or disability insurance coverage. It is the Volunteer/Guardian's personal responsibility to check with your local insurance carrier about primary accident coverage for you while in transit and on-site at work projects. Each Volunteer is required to provide proof of evacuation insurance for international destinations. The Volunteer/Guardian is advised to obtain a policy for medical insurance. I attest my understanding and agreement by checking the box.
I agree to the responsibility consent.
I bear full legal and financial responsibility for myself, including responsibility for all indebtedness or other legal obligations incurred by me while on this mission. I attest my understanding and agreement by checking the box.
RIGHT TO REQUIRE WITHDRAWAL
I agree to the right to require withdrawal consent.
At any time prior to or during the mission, Power of a Nickel, Inc. shall have the right to require my withdrawal from the mission if it is determined in Power of a Nickel’s sole discretion, that my ongoing participation may be detrimental to me, to others, or to Power of a Nickel, Inc. I attest my understanding and agreement by checking the box.
I agree to the travel risk consent.
It is my responsibility to review information from the U.S State Department and CDC regarding the travel risks in the countries to which I will travel and to obtain appropriate immunizations and prophylactic medications prior to the mission trip. I attest my understanding and agreement by checking the box.
PHOTO & VIDEO
I agree to the photo & video consent.
By participating in a Power of a Nickel Global Outreach Trip, I give Power of a Nickel the right to use my image in photo or video and my comments for publicity purposes related directly to the mission of Power of a Nickel. I understand that I will not be compensated should the images or comments be used in our media pieces. I attest my understanding and agreement by checking the box.
I agree to the this release.
Volunteer and Guardian expressly agree that this Release is intended to be as broad and inclusive as permitted by the laws of the State of Oklahoma. Volunteer and Guardian agree that in the event that any clause or provision of this Release shall be held to be invalid by any court of competent jurisdiction the invalidity of such clause or provision shall not otherwise affect the remaining provisions of this Release which continue to be enforceable. I attest my understanding and agreement by checking the box.
I acknowledge that I have read and understood the above releases and information. This box serves as my electronic signature
THIS RELEASE AND WAIVER OF LIABILITY executed on this day as indicated above, by, (volunteer name), and if there is a parent having legal custody and/or the legal guardian of the Volunteer (“the Guardian”) in favor of The Power of a Nickel, Inc. and its directors, officers, employees, and agents. The volunteer and/or Guardian understand that mission work activities may include medical mission work, being transported to and from project locations, and consuming food and living accommodation donated or purchased for the volunteers. I, the Volunteer and/or Guardian will participate in this mission as my free and voluntary act and do hereby without duress execute this Release and Waiver of Liability
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Your application is not complete until we receive your deposit. Please go to the page "Deposits" under the JOIN A TRIP tab.
I am in the "looking" stage
I am fairly certain I will join the group
I am heading over to the Deposit/Payment page
Your space is not reserved until you have completed the Team Application, made your deposit, and received a confirmation from Power of a Nickel.
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