APPLICATION
Midwifery & Health in the Americas: Weaving Maya & Western Medicine
Service-Exchange Program –July22-29, 2017
Name: ______(exactly as it appears on your passport)
Date/Year of Birth ______
Address: ______
Daytime phone: ______Evening or cell phone: ______
E-mail address: ______
Department/Affiliation/Major: ______
Passport number: ______Nationality: ______
Passport expiration date: ______
How did you learn about the program?
Please share why you would like to participate in this program?
Please share any relevant health experience globallyand/or in women’s health, maternal and/or child healththat you have had.
Please share any personal objectives and expectations for this trip? What do you hope to accomplish?*
Detail any other jobs, experiences, or qualifications that you believe would be relevant to the team.
Do you have any preliminary ideas on knowledge, skills or an activity you would like to share with the Maya midwivesand community leaderswe spend time with?
How do you anticipate using this experience in the future when you return to your community?
Please rate your language proficiency (circle one):
Spoken Spanish: fluentgood fair poor none
Written Spanish: fluentgood fair poor none
Note:We will be ‘living’ and working in Quetzaltenango which is located in a mountain valley at an elevation of about 7,655 ft. Some short term hiking may be involved and it often rains a lot at this time of the year. If you have any health concerns or physical limitations related to these conditions please note below.
Do you have any health conditions that might be a concern while traveling? ____ YES ____NO
IF YES PLEASE EXPLAIN:
I expect I am interested in having Highland Support Project purchase a ticket for me as part of the group travel.
Yes ______No ______(More info will be provided as soon as we get all the flight purchase decisions)
Hosted by the VCU Institute for Women’s Health, and the
Highland Support Project
______
PLEASE RETURN THE ABOVE 2 PAGE APPLICATION FORM
Application deadline May 20, 2017
Send to Janett Forte, by e-mail to:
or by fax to (804) 827- 0957 or by mail to:
Institute for Women’s Health, PO Box 980319, Richmond, VA 23298-0319
The total cost of the exchange is $985.00 per person to cover coordination, logistics, food,
lodging, in-country transportation, cultural activities and language translation. Trip emergency medical, evacuation, and liability insurance is also included.The deposit will be included in this cost.
If selected, a payment in the amount of $985.00 is due by May 26, 2017.
For questions or clarifications, please contact Janett Forte at
Notices of application acceptance will be sent by May 22, 2017
Some PreliminaryLogistics – FYI
Team Leader: Elizabeth (Beth) Collins works in the VCU Research & Innovation Office – as a Clinical Research Auditor.Beth is a bioethicist and clinical research professional. Currently in VCU’s doctoral program in Media, Art, & Text(MATX), Beth's academic focus is in narrative medicine/ethicswith base interdisciplinary ties to the fields of philosophy, anthropology, and healthcare.
Beth participated in one of our midwifery- health teams in 2013.Beth in partnership with another 2013 team member Amy Whitehurst, captured in photos their experience from the “Marrying Mayan & Western Medicine” service trip in hopes of supporting the holistic health work being done within these indigenous circles of women by exposing the haunting beauty of Guatemala as well as the need for human rights/multicultural understanding.
Trip Details: The standard 8 day trip with all expenses paid includes all in country transportation, food, lodging cultural activities and translators. The cost is $985.00plus airfare, which is usually about $650.00. This fee also covers the cost of the emergency medical, evacuation, and liability insurance policy that covers every traveler on the trip.
Airfare:
There are a few options for purchasing airfare for your service trip. HSP is more than happy to find and purchase airfare for the team, or individual team members may purchase their own tickets.
If team members are purchasing their own airfare, it is ideal that all team members travel on the same flight, and HSP can facilitate communication between team members regarding available flights and travel options. It is IMPERATIVE that team members arrive in Guatemala NO LATER THAN 2:00 pm! This is required to ensure the safety of the team as they travel out of Guatemala City.
If HSP is purchasing airfare for the team, airfare will be purchased after team members remit an airfare deposit, typically included with the 2nd trip payment. HSP will not purchase a plane ticket before payment has been received. Once tickets are purchased, the team members for whom the tickets are purchased are responsible for any additional airfare related costs needed, including, but not limited to, baggage fees and ticket changes.
The round trip cost is around $650. We will search for the best price and travel logistics. Flights are at times out of Richmond, but often will be out of the Washington DC area – either DCA or IAD airports.
Trip Planning Meetings:
Information Session:
A pre-trip planning meeting will be hosted in June (Date TBD)at theHighland Support Project office. We will have a chance to begin to build the team - sharing ideas and interests. At the meeting we will provide more information on the context for women’s health in Guatemala, including some history on health related trips and health initiatives in Guatemala. We will provide updates on trip logistics, completion of paperwork, and encourage input for our in-country project itinerary. Karen Mayorgaand Guadalupe Ramirezfrom HSP will join us and will be available to address any questions related to final logistics, packing recommendations etc.
Trip Timeline and deadlines
ALL APPLICATIONS ARE DUE by May 20, 2017
Notices of application acceptance will be sent by May 22, 2017
Deadlines - The trip is scheduled for Saturday July 22 to Saturday July 29, 2017
Payment Schedule
The total payment for the trip is $985.00. Your program fees cover food, lodging, interpretation, meeting facilitation, and transportation within Guatemala. This fee also covers the cost of the emergency medical, evacuation, and liability insurance policy that covers every traveler on the trip.
Note: You are welcome to pay the total program fee in one payment or utilize the 3 step payment option below.
A non-refundable deposit of $250 is due by due byMay 26, 2017 and date to notify us of your decision about purchasing airline tickets.
June 9, 2017 - Second Payment of $367.50 and airfare*(about $650.00) due. (Generally the earlier we purchase tickets for the group– the better the price)
If HSP is purchasing your airfare and the true ticket cost is different from the $650 estimate, the final payment will be adjusted to reflect the difference in cost.
If you’re purchasing your own airfare, purchase your ticket by June 22 and send us your flight details. Your 2nd payment will not include airfare cost and is then ($367.50)
30 days before departure date = June 22, 2107 - Remaining balance of payment due ($367.50) or the difference based on adjustment for airfare cost for those that had HSP purchase tickets
Saturday, July 22, 2017– On our way – Depart for Guatemala!
*********
Checks are made payable to Highland Support Project and need to be mailed to HSP c/o Karen Mayorga - PO Box 7185 Richmond, VA 23221 or dropped off to KarenMayorgaat the HSP office 700 W. Franklin Street, Richmond. Please call ahead: Karen’s cell # is (804)464-3467
4.14.17 final
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