Metroplex Health System

Haiti Mission Trip 2012

Application for Volunteer Participation

Full Name ______

Name You Go By______Date of Application______

Mailing Address ______

City______State______Zip______E-Mail______

Home Phone______Cell Phone______

Place of Work ______Work Phone______

Date of Birth______

Passport #______Expiration Date______

Attach Copy of Your Passport (the page with your picture and information)

(You will NOT be able to participate on the trip if you do not have a passport)

Why would you like to participate in this type of mission project? ______

______

______

On the mission trip I am interested in helping with the following (check as many as apply):

 I am willing to have a morning or evening devotional (2-3 minutes)

 I am willing to pray at worships or before meals

 Kitchen help

Payment for the Trip:I understand that ultimately I am responsible for raising the funds to cover my expenses on the trip. The deadline for payment is August 15, 2012

Signed______Date______

Release of Liability and responsibility of Applicant

I (print name)______, have voluntarily chosen to join the Metroplex Hospital 2012Mission Trip. I hereby release and hold harmless Metroplex Hospital, Adventist Health Systems, their respective officers, directors, employees, the project leaders, or any member of the team, from any and all injury, loss and/or damage to my/applicant’s person or my/applicant’s property, regardless of whether the injury, loss or damage is attributable to the negligent act or omission of any of the aforementioned.

Participant’s Signature______Date______

Spouse’s Signature______Date______

The undersigned are the legal parents or guardian of the applicant referred to above, and agree(s) to the foregoing release of Liability and Responsibility of Applicant.

Father/s Signature (if minor)______Date______

Mother’s Signature (if minor)______Date______

Metroplex Health System

Haiti Mission Trip 2012

Code of Conduct

Metroplex Health System, as part of the Adventist Health System (AHS), has principles and a code of conduct that are standard for all the hospitals in the system. The Mission Trip 2011, sponsored by Metroplex Health System also has a code of conduct that it requests its participants follow. As a mission team from Metroplex and AHS and as organizers of our project, all these organizations are judged by our behavior on our trips. Therefore, the following code of conduct will be expected.

  1. As Metroplex and AHS prohibit the use of alcohol, it is expected that you refrain from the use of alcohol on the trip. This includes the project site, our lodging during the project, and on any excursion time when you are still representing Metroplex. We want the “off-time” to be fun and relaxing for everyone, and believe that can be achieved without the use of alcohol.
  2. We request that during the week nobody leave our lodging place on their own after the evening meal and/or meeting. If an emergency arises or something is needed, check with project coordinator before leaving the hotel/lodging site. During the day at the project site we also request that you let the project coordinator know if you need to leave for any reason.
  3. As our teams are comprised of males, females, married and singles, we request that male/female interactions be appropriate at all times, and do not make others uncomfortable. There will be no male/female sharing of lodging at night. Disregard of this will be cause for being sent home on the next available plane at participant’s own expense for the charge.
  4. There are to be no inappropriate male/female interactions with the Local or others outside the group, or situations that cause any local people to be uncomfortable. If this occurs, participants will be counseled by mission project coordinator and/or senior hospital officer on the team. Should inappropriate actions continue, participants will be sent home on the next available plane at participant’s own expense for the charge.
  5. Smoking is prohibited at the worksite and lodging.
  6. The purchase and/or use of drugs are prohibited on the trip. Disregard of this will be cause for being sent home on the next available plane at the participant’s own expense for the charge.
  7. As we are the guests where we go, it is expected that team members show respect for the people, their culture and their way of doing things. There will be no swearing or inappropriate language. In issues of appropriate cultural behavior/interaction, the project coordinator will be the final authority.

I, (print name)______have read the above code of conduct and agree to abide by it.

(Signed)______Date______

 Yes  No - I have health insurance that will cover my medical bills

Name of Insurance Company______

Policy #______Insured’s Name______

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