PROJECT INTERNATIONAL PARTICIPATION AGREEMENT
As representatives of this Medical Mission Program, working with
INTERNATIONAL CHILDREN'S MEDICAL FOUNDATION, (ICMF) and as a guest in a host
country, participants are expected to abstain from using illegal drugs and
publicly using alcohol and tobacco. They also should refrain from
attending discos and bars for the duration of the ICMF Medical Mission Project.
DOCTORS/NURSES INFORMATION pages must be read; with participants agreeing to adhere
Click Here For A Downloadable PDF Copy Of The Project International Participation
Please fill out and mail the form to the address indicated below with
two passport size photos.
Name:_____________________________________ D.O.B.___________ M____ F____
State: ________________ Zip:_________
Phone: _________________ Fax:________________
M..D. SPECIAL FIELD OF TRAINING: _________________________
RESIDENT - WHAT YEAR?_______________
NURSE SPECIAL FIELD OF
TECHNICIAN - SPECIAL FIELD
OTHER - EXPLAIN:
Have you ever participated in any foreign medical mission trips
If so, with whom: _______________________________________
WOULD YOU BE WILLING TO ASSIST IN GETTING ONE OF OUR MEDICALLY NEEDY
CHILDREN HELP IN A HOSPITAL IN YOUR AREA?
IF SO, WOULD YOU BE LOOKING FOR ANY KIND OF "SPECIALTY" CASE?
STATEMENT OF HEALTH STATUS
INTERNATIONAL CHILDREN'S MEDICAL FOUNDATION
needs to know:
(1) Are you taking any medication on a daily or continuing basis?
Yes___ No____ If yes, please list______________________________________
(2) Are you disabled, or limited in activity because of any present
or previous illness?
Yes_____ No_____ If yes, please give details:
(3) Do you have dietary restrictions? Yes____ No___
If yes, please use separate page and detail.
By answering these questions, you make the ICMF team leader's job
easier if you, the participant, require assistance. (If additional space is
needed, please use an additional sheet)
PROJECT INTERNATIONAL WAIVER
I, ______________________________________, in consideration of the
benefits derived, if
accepted for a Medical Group Mission project, hereby voluntarily waive any claim
against the local and international organization, the Ministry of
Health/Govt. of the host country, ICMF local officers, its sponsoring institutions and all
leaders of INTERNATIONAL CHILDREN'S MEDICAL FOUNDATION for any and all causes
in connection with the activities of the above organization. Waiver must
be signed by every applicant.
I understand that the participation fee covers all ICMF office operational expenses
(which varies from project to project), and is payable to:
INTERNATIONAL CHILDREN'S MEDICAL FOUNDATION . This fee must be in our U.S. office 60
DAYS BEFORE I LEAVE for the project.
I understand that a deposit of $200.00 (for nurses) and $300.00 (for
doctors)must accompany my application, and my check, payable to:
INTERNATIONAL CHILDREN'S MEDICAL FOUNDATION (PO Box 770795 - New Orleans, LA - 70117)
is enclosed. I understand that this deposit is non-refundable but may,
in the event of cancellation , with notice given, be transferred one time only
to the next up-coming project.
I am applying for Medical Mission Project Date(s): __________________________________ (If currently unscheduled,
How did you hear about ICMF?
Are you part of a group applying for this project? __________ If yes,
SPECIAL NOTE: Due to the effects that Hurricane Katrina has had on
the U.S. mails in the New Orleans area we are asking that all
Participants submit their deposits directly to us via PayPal.
Are you shopping for a special person in your life?
Be sure to visit our Fundraising Store: Agape Treasures
All proceeds from Agape Treasures purchases will be your
*secure*direct deposit contribution into ICMF's bank
If you are not shopping today and/or are unable to otherwise
Participate, would you consider making a
monetary donation? We value your gift, whether great or small, remembering and
telling our children that someone “out there” cares about
It’s people like YOU who make it possible for us to continue
this great outreach. Know that you will be rewarded for your
Donate with any major credit card through PayPal! It's SECURE, FAST