General Contact Information


Work Experience/Talents


Please list any additional talents that you have.
Business
Finance
Writing
Public Health
Ministry
Music
Children
Accounting
Technology
Photography
Other (Please Specify):

Additional interest to pursue during trip.
Music
Photography
Videography
Children
Shadowing of Medical Professional (Please Specify)
Writing
Ministry
Other (Please Specify):

Personal Information






If you are applying for a trip that includes interaction with children, you may be required to have a background check. Will you agree to a check? Yes No

Please list two non-family references.



OWH works closely with the local church in order to achieve quality results at our outreach clinic sites. We will begin each day on the trip reading and discussing a passage of scripture from the Bible (You will not be expected to lead discussion). Do you agree to participate in this aspect of the trip?
Yes No
Volunteers are expected to share their life story with the team after dinner at night. Do you agree to be open to sharing your life story with other volunteers?
Yes No
Do you attend a church? Yes No
Do you participate in local, community service? Yes No
If yes, please explain:

Health Information


Do you have or have you ever had (check all that apply):
Fainting Spells
Heart Problems
Diabetes
Psychosis/Schizophrenia
Eating Disorders
Respiratory Problems
Seizures/Neurologic Disorder
None of the Above

Do you have any condition that may affect your ability to fully function on this trip? (i.e., fear of flying, depression, anxiety, sleeping disorders)
Yes (please explain)

No
Do you have any chronic illnesses or allergies?
Yes (please explain)

No
Are you presently under medication prescribed by a doctor?
Yes (please explain)

No
Have you ever had any psychiatric care or treatment?
Yes (please explain)

No


Emergency Contact Information


Application Fee

/ mm/yyyy

Applicant Agreement

The information I have provided is true and complete to the best of my knowledge and I authorize OneWorld Health (OWH) to verify the authenticity of my statements with the appropriate authorities, including criminal background checks on applicants, doctor’s reference or exam, and personal reference contact.

OWH requires compliance with rules and regulations, including the rules concerning conduct and dress. These are explained in the Team Covenant, which will be provided to accepted volunteers. Failure by volunteers, leaders and staff to comply with these policies is grounds for dismissal, without refund or reimbursement. Volunteers, leaders, and staff serve at their own risk, and OWH is not liable in the event of sickness, accident, death, terrorist acts or for transportation and any other expense beyond normal involvement.

Application fees and all sponsor funds received by OWH are contributions and are not refundable. To receive a tax deduction, the IRS stipulates in Publication 526 on Charitable Contributions that the donor must release control of all funds donated to a non-profit organization. For this reason, contributions from sponsors cannot be refunded, nor can they be designated to any specific person. The individual will be a fundraiser and will receive credit for raising funds equal to the price of his/her trip. We require all participants to be in good physical condition.

I have read and understand the above information. The information I have given OWH is accurate and true to the best of my knowledge. My signature signifies my approval of all limitations and conditions listed above. If any information on this application is materially incorrect, I understand that my participation in this program may be terminated.  Also, I understand that it is very important, and my responsibility, to immediately update OWH, in writing, with any changes to the information on this application.


By checking this box, I authorize my signature electronically.

Assumption of Risk Agreement

In connection with my application for volunteer service to OneWorld Health, represent and agree, as follows:

(A)
I am aware of the hazards and risks to my person and property associated with the overseas, disaster relief or medical/evangelism missionary activities for which I am applying and I understand that such hazards and risks include, but are not limited to, death or injury by accident, sickness/disease, terrorist acts, the inherent uncertainty of foreign travel, weather/temperature conditions, and inadequate medical transportation, supplies and facilities. I volunteer my services to OneWorld Health and to the people of Masindi despite such hazards and risks, and I assume the risks of death, sickness, injury, inconvenience and/or damage, actual or consequential, associated with such known or unknown risks.

(B)
I attest and verify that I am physically fit for this volunteer service, that I understand the potential risks of this volunteer effort, that I have consulted with a medical professional of my choice, and to the best of my knowledge have no medical conditions that would prevent me from performing the volunteer services for which I am applying.

(C)
In consideration of travel and other arrangements made for me by OneWorld Health, and on behalf of myself, my heirs, and my personal representatives, I hereby release and discharge OneWorld Health or other of its officers, directors, agents, employees, or other representatives from and against any losses, liabilities, damages, costs or expenses, including reasonable attorney fees, arising out of my participation, in this trip, whether in transit, at all times as a volunteer service provider, or during any optional sightseeing trips or excursions; including but not limited to personal harm/injury, or property or other damage from any such known or unknown risks. I expressly waive any and all claims for losses, liabilities, damages, costs or expenses (including those contracted for on my behalf in paragraph D) which I may have against OneWorld Health, its agents, or employees, including claims based on their ordinary negligence, now or at any future time. Throughout my volunteer effort, I will provide my own insurance coverage at my own expense.

(D)
I understand that travel and work will be in an underdeveloped nation or in an area affected by strife and natural disaster; therefore, it may be difficult or impossible for OneWorld Health or its agents or employees, to guarantee or meet evacuation, medical, or special dietary needs. In the event of a medical emergency I hereby authorize officers of OneWorld Health to contact my emergency contact persons, to discuss my health information with medical personnel, and to seek, and contract for as necessary, medical care, evacuation and treatment on my behalf,


By checking this box, I authorize my signature electronically.

In connection with my application for volunteer service to OneWorld Health, represent and agree, as follows:

I hereby acknowledge that I am responsible for the entire cost of my trip as given by OneWorld Health. The first half of my fundraising goal is due six weeks prior to departure. The remaining balance is due two weeks prior to departure and must be in the possession of OneWorld Health to be considered complete. If for any reason I do not meet my goals by this deadline I understand that my airfare will be cancelled and I will be charged a $350 cancellation fee if applying to Uganda or will be responsible for the full price of my airfare if applying to Nicaragua.


By checking this box, I authorize my signature electronically.