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Global Health Outreach Participant Application

Thank you for your interest in participating in a Global Health Outreach (GHO) Trip associated with DOCARE International, a not-for-profit organization.

Fields marked with an * are required.

Please verify that you have checked the “I'm not a robot” checkbox.

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General Trip Questions

Iquitos, Peru (March 2024)
Antigua, Guatemala (March 2024)

Pre-Health Student (Undergraduate)
Medical Student
Resident
Physician
Nurse Practitioner
Registered Nurse
Physicians Assistant
Pharmacist
Translator
Volunteer
Other

Neurology
Rheumatology
Geriatrics
Gynecology
Endocrinology
Otolaryngology
Cardiology
Orthopedics
Family Medicine
Emergency Medicine
Pediatrics
Ophthalmology
Pulmonary
General Surgery
Dermatology
Internal Medicine
Other

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Release from Liability & Acknowledgement of Risk
I apply to DOCARE International NFP (“DOCARE)”, an Illinois not-for-profit corporation with offices located at 1350 Main St., Suite 1100, Springfield, Massachusetts, to participate in the upcoming global health outreach opportunity with DOCARE.

please include country code if outside of the United States

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Terms of Agreement

In order to be considered for any DOCARE opportunity, each applicant must be a current DOCARE Member. Join by visiting docareintl.org/become-a-member.

I certify that I am a current DOCARE Member with my dues having been paid.

I will participate in this outreach opportunity as my free and voluntary act.

I Agree
I Disagree

I recognize and assume all risks and expense as a result of participating in global health outreach. These risks include but are not limited to the following:

  1. Exposure to blood-borne pathogens and other potentially infectious materials where ability to access immediate treatment may be limited
  2. Personal injury such as accidents inherent to travel in motorized vehicles
  3. Sickness including exposure to endemic infectious disease
  4. Death

I Agree
I Disagree

I understand medical and evacuation insurance is required for all participants with a minimum coverage level of $500,000 to include repatriation if necessary. In addition, cancellation insurance is recommended (but not required).

I Agree
I Disagree

My travel to and presence in a foreign country will expose me to potential risks of disease, injury, and physical and emotional harm, including death, that I would not otherwise be exposed to.

I Agree
I Disagree

DOCARE is not a travel advisory service. It is my responsibility to review information from the U.S. State Department and other organizations regarding the travel risks involved for the host country.

I Agree
I Disagree

Laws of the host country will apply, and I will be subject to the host country's jurisdiction.

I Agree
I Disagree

I bear full legal and financial responsibility for myself including responsibility for all indebtedness or other legal obligations incurred by me while participating in this global health outreach.

I Agree
I Disagree

DOCARE shall have the right to require my withdrawal from the global health outreach if it is determined in DOCARE's sole discretion that my ongoing participation may be detrimental to me, to others, or to DOCARE.

I Agree
I Disagree

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COVID-19 Travel Policy

  • Must be fully vaccinated for COVID-19 as defined by the CDC guidelines at the time of departure for the trip. (www.cdc.gov/coronavirus/2019-nCoV/index.html)
  • Shall not travel if feeling ill or having been ill in the weeks preceding travel.
  • Must comply with CDC guidelines for travel if recently COVID-19 positive or symptomatic. (www.cdc.gov/coronavirus/2019-nCoV/index.html)
  • Must have access to PPE (masks: surgical/N95/KN95; disposable gowns, gloves, hand sanitizer). Participant is responsible to determine who will provide this, and precisely what is required at the time of the trip.
  • Must comply with PPE the recommendations of the location of the trip as well as USA guidelines, following the more inclusive guidelines.
  • Will adhere to rigorous sanitation practices at all times.
  • Shall be responsible to monitor for current travel advisories.
  • Must travel with vaccination documentation at all times.
  • Are required to obtain medical and evacuation insurance with a minimum of $500,000 coverage to include care and accommodations for COVID-19 related illness. This must include medical care that may extend past the trip termination date in the event departure is delayed for care/isolation at conclusion of the trip.
  • Be responsible for isolation expenses if required during or at trip conclusion.


I have reviewed and agree to the COVID-19 Travel Policy.

I Agree
I Disagree

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Formal Acknowledgement

I, do for myself and my heirs, executors, administrators, legal representatives and assigns (hereafter, collectively, “I” or “me') hereby release, forever discharge and agree to hold harmless DOCARE International, its directors, officers, agents, employees and clinic staff and employees from any and all liability, claims or demands for personal injury, sickness or death, as well as property damages and expenses, of any nature whatsoever which may be incurred by me in connection with or resulting from my participation in the DOCARE global health outreach.

I Agree
I Disagree

I certify that I have read and fully understood the provisions of this Release from Liability and Acknowledgment of Assumption of Risk and had the opportunity to review it with an attorney of my choosing if I so desire. I agree to be legally bound by this Release.

I Agree
I Disagree

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