InternationalHealthService
Participant Application please print clearly
February4February 28,2020
Note:TheFebmissiondatesarethelatestarrivaldateinLaCeiba(usuallybyplanetoSAPfollowedbybus)andtheearliestdeparturedate.TheFeb2020
mission begins Friday evening Feb 14 and ends Thursday evening Feb 27. Many participants on the trip will extend to Sunday,March 1, 2020 to
accommodateanoptionalsidetrip.Thisisimportanttoknowwhenyougetairlinetickets.
Name:_____________________________________________ HomePhone:_____________________________
Address:___________________________________________ CellPhone:_______________________________
City:______________________ State:__________________ Dateofbirth(D/M/Y):______________________
Zip:___________________ Country:___________________ Nametoputonnametag:____________________
E-mail:_____________________________________________Male Female
Pleasemarkthetypeofteamassignment(s)youprefer(checkALLthatapply)
Please take note: We cannot always guarantee you will be placed at your preferred choice
AdminteamLaCeiba LogisticsteamPLP Eyecare
Riveremote(LaMosquitia)Inland(mountains,etc)SurgerynyassignmentOK
Listspecificteamsitepreference (ifany)______________ListanyassignmentyouwouldNOTaccept__________________
NumberofpreviousIHSprojectsyouhavebeenon_______ Wouldyoubewillingtobeateamleader?________
HowwelldoyouspeakSpanish? NoneWordsPhrasesConversationalFluent
(Application - continued on next page)
Specialty(checkallthatapply)SendcopiesoflicensePhysiciansanddentistsmustalsosendcopiesofdiploma
____DDS(specialty)_____________________________ DentalAss’t RDH RPh
PA Paramedic____MD(specialty)______________________________ NP
____RN(specialty)_______________________________ LPN
____OD Interpreter RadioOperator
CRNA EMT
____Engineer ____GeneralHelper
Other(pleasespecify)________________________________________________
Whereareyoucurrentlyworking?________________________ Ifnot,whendidyoulas
tworkinthisfield?____________
Nameofcurrentorpastsupervisor________________________________ Phone_________________________
Brieflydescribeyourworkexperience:
____________________________________________________________________________________________

*
Due
Application/Depo sit/Licenses
$125
Due December 15
Project fee balance/Paperwork
$625
Total February project fee
$750
*
Applications received before first due date for the project will receive priority in
team assignments. Those received after will be consider ed only if their specialty is needed.
For applications to be c onsidered the following must be attached:
- Completed application with s igned waiver - Deposit
- Copy of professional licenses - Physicians & Dentists: copy of diploma also
- Copy of Amateur Radio license ( Radio operators only)
Note:
$1
25 deposit
is
non-refundable
and
due with the completed
application. Upon request,
deposit will be refunded if your
application is not accepted.
Makecheckspayableto:
InternationalHealthService
Mailapplication&formsto:
IHS-Attn:ProjDir
3500 Vicksburg Ln N, PMB 405
Plymouth,MN55447
Application Deadlines & Project Fees
February Trip
How or from whom did you hear abo ut IHS? ____________ ___________________________________ __________________
Please list any major surgeries or serious illnesses in the past 5 years __________________________ __________________
Mark Yes if you are able and No
if not able and explain any limitations below:
_____ Lift and carry 25 pounds multiple times _____ Climb two or more flights of stairs
_____ Work in extreme heat and humidity _____ Walk on uneven terrain
_____ Travel by any type transportation _____ Bend or stoop multiple times
Explain any limitations ____________________________________________________________________________
_______________________________________________________________________________________________________________________
First time participants must also complete the Project Suitability Form on the next page.
INTERNATIONALHEALTHSERVICE
ACKNOWLEDGEMENT OF RISK AND WAIVER OF RESPONSIBILITY
I,(printname)_______________________________alongwithallmembersofmyfamily,inconsiderationofthebenefits
derived,ifacceptedfortheInternationalHealthServiceproject,herebyvoluntarilyacknowledgetheriskIamundertaking
andwaiveanyclaimagainstthelocalandinternationalorganization,localofficers,itssponsoringinstitutionsandallleaders
ofInternationalHealthServiceforanyandallcausesinconnectionwiththeactivitiesoftheaboveorganization.
The use of ille gal drugs is strictly prohibited by IHS and alcohol consumption by team members during the mission
workdays is against I HS policy. In addition, team members should use alcohol with discre tion, in moderation, and be
sensitive to local customs regarding the use of alcohol. I understand t hat as a volunteer I represent IHS and agree to abide by
this policy.
InternationalHealthServicedoesnotprovideanytypeinsurance(medical,liability,travel,medicalevacuation,life)for
anyparticipants. MysignatureonthisformindicatesmyfullunderstandingthatImustprovidemyowninsurance.
Signed __________ _________________________________ _____ Date ______________________________
PHOTORELEASE
InternationalHealthServicerequestspermissiontousephotographsandnarrativedescriptionsofparticipantsandthe
worktheydoonprojectsforthepurposeofpublicrelations,advertisingpromotions,andfundraising. Thesephotosmay
beusedin,butnotlimitedto : Powerpointpresentations,theIHSNewsBreak,andtheIHSwebsite. This
authorizationisonlyfortheIHSorganization. IHShasnocontroloverhowteammatesandotherparticipantsusephotos
forpurposesoftheirown. Thisauthorizationwillremainineffectforatleastoneyear. IHScannotguaranteethatyour
imagefromthistripwillnotbeusedafterthatperiodoftime.
Yes, you may use my photo !
Signed __________ _________________________________ _______ Date _____________________________
No, I prefer you not use my photo.
Signed __________ _________________________________ _______ Date _____________________________
If you select NO, please make sure one team picture is taken excluding you, to submit to the annual Newsbreak sta ff.
It is your responsibility t o submit the correct picture to the Newsbreak editor.
T-SHIRTS & CAPS…… T-shirts and caps are not included in the project fee and are a separate fee.
February Trip Orders and payments for these items will only be accepted until 15 November so plan ahead.
(T-shirtsizesavailableare:SMLXL2XL)
T-shirts@$15-howmanysize
 Caps@$12
howmany
Please include the cost for these items with your deposit and this application.
INTERNATIONALHEALTHSERVICEProjectSuitabilityForm
(requiredoffirsttimeparticipantsonly)
IHS projects are not for everyone as some locations are very remote and some people react differently when placed in
a situation different from their normal life. To assist you in determining if this project i s ri ght for you and to assist
us in placing you on the correct team, please complete t his form and return with your application
.
All IHS projects begin in La Ceiba, Honduras. Upon arrival participants will stay one or two night s in a hotel or with a local
host family during our orientation programs. Teams will also return to La Ceiba at the end of the project, usually for one night,
for d ebriefing, storing supplies and equipment plus a farewell dinner. Also, many repeat participants return to the same location
as they get to know the local people.
The following questions are not meant to discourage you. Instead we hope they gi ve you an understanding of the places we go
and challenges that may happen.
Briefly descr ibe any camping, hiking, or adventure trip experience you may have had. ________________________________
_______________________________________________________________________________________________________
Remote areas of Honduras have limited electricity or modern transportation and few telephones. Many IHS participants return
year after year so they understand this change o f life and the experience of helpin g people in this environment. Can you honestly
say you can handle 8 to 10 days in locations that have solar showers, outhouses, bugs, humidity and the possibility of sleeping in
a screen tent? __________ _______ Comments: _____________________________________ _________________________
______________________________________________________________________________________________________
For many, the time at the team site will be spent in a remote location away from telephones and TV with people who speak a
different language, use different money, and have different habits, values and social norms. Can you handle being d isconnected
from friends and family for two weeks? _________ How do you plan to keep busy d uring quiet/slow hours? _____________
______________________________________________________________________________________________________
Most of Honduras experiences a hot and humid climate. Mountain teams may get chilly at night. Many participants will do a lot
of walking on uneven ground, carrying their own bags, lifting, moving, loading, and unloading many boxes of supplies. Can you
do your share o f the work and are physically up to going on this trip ? _____________________ __________________________
Frustration can happen on the trip. You are in a foreign country wher e Murphy’s law can happen. You may experience “hurry
up and wait”. You will b e with a group of people you have never b e en with before and interacting with a different culture. All
this can be challenging. Ho w do you handle frustration? ________________________________________________________
Does your temperament allow you to “not sweat the small s tuff”? ________________________________ __________________
IHS teams may see many patients, which can require long days. Some teams will be working in hot, humid locations. How is
your temperament and physical stamina in times like this? __________________________ _____________________________
Teams that have the most enjoyable experience work together with each team member co ntributing their part to the group’s
overall function. This requires you to do your job well every da y, trusting ot hers to do their job, and always stepping up to help
with the small tasks that need to be done every day. To what exte nt are you a team worker? ___________________________
______________________________________________________________________________________________________
There will be ti mes when people work with patients in their own spec ialty. However, many tasks require the help of ALL team
members working as a team. Group decisions are made when possible but the Team Leader has final say. Can you work within
a group and b e respectful of decisions made? _________________________________________________________________
*** February team only…. some team sites have limited local communications so they also have ham radio operators who use radios to talk
with the Admin team and Project Director in La Ceiba plus the logistics team in Puerto Lempira. There is telephone and/or cell phone use at
some team sites. Many radio operato rs also have a limited e-mail capability. In the unlikely event of an emergency the Project Director and all
radio operators work together to make sure the correct people are notified as soon as possible. Because electricit y and other services are not
available all the time, we need to und erstand that everyone will d o t heir best to be timely but things do not always happen instantly.
Participants need to tell family and friends at home about this situation. As with all details of each team site, participants will get information
from their Team Leader about what communications and site facilities will be available for their use.
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