Outreach / Mission Trips / Haiti Trip Application
Date of Birth*
Which Haiti trip are you applying for?*
Please describe your current occupation and/or work experience.*
Please provide the name and contact information of a church or staff member who knows you well.*
Please list any church, ministry or small group activities that you are involved in.*
Please tell us a little about yourself.
Please list any previous global mission experience you've had.*
What is the greatest asset you believe you can bring to this team?*
What is one aspect of your personality that could make this trip difficult for you?*
Is there anything else you'd like to share about yourself that may be relevant to this experience?*
Due to the current conditions in Haiti, we would like for you to acknowledge that you are aware of the following before committing to travel to the country.
The US State Department has issued a travel warning for Haiti, discouraging Americans from traveling to and from the country. The state department travel advisory can be found at:
Please check "I understand" if you acknowledge that you were made aware of this warning.
Haiti is experiencing an outbreak of Cholera. When traveling, eating, drinking, brushing your teeth and showering in Haiti, you run the risk of contracting Cholera through the water, and there is also risk of occupational exposure in medical and other mission settings. HPUMC requires that you bring with you a full dosage of antibiotic treatment to be used in case of infection. CDC recommendations can be found at:
http://www.cdc.gov/cholera/treatment/antibiotic-treatment.html. Please check "I understand" if you acknowledge that you were made aware of this outbreak.
Haiti is experiencing an outbreak of the mosquito borne Zika virus. There is not a vaccine to treat or prevent Zika. While the virus is not deadly, it is known to cause serious birth defects for pregnant women. More information can be found at: http://www.cdc.gov/zika/. Please check "I understand" if you acknowledge that you were made aware of this outbreak.
The US State Department recommends that all travelers to Haiti be up to date on routine vaccinations before traveling (measles-mumps-rabies, diphtheria-tetanus-pertussis, chickenpox, polio and annual flu shot). In addition, HPUMC requires all travelers to receive Hepatitis A and B and Typhoid vaccinations and to take Malaria medication as directed by your doctor. CDC recommendations for travel to Haiti can be found at: http://wwwnc.cdc.gov/travel/destinations/traveler/none/haiti. Please check "I understand" if you acknowledge that you were made aware of these requirements.
I am not comfortable with the increased risk of serving in a surgical area but am willing to serve in a non-surgical role. I acknowledge the risk of occupational exposure and agree to comply with HPUMC’s protocol if exposure occurs.
I am willing to undergo the increased risk associated with serving in a surgical area and agree to comply with HPUMC's protocol if exposure occurs. I agree to travel with HIV PEP medication to last the duration of the trip.
There is a risk of occupational exposure to disease when working in medical, construction and other mission field environments. This may include exposure to HIV, Hepatitis, STDs, TB, etc. The risk of exposure to bloodborne pathogens is greatest for those working in the OR. If you choose to serve in the surgical area (not required), HPUMC requires that you travel with HIV PEP (Post Exposure Prophylaxis) medication to last the duration of the trip. In case of needle stick or other exposure we require that you agree to comply with HPUMC’s “Bloodborne Pathogen Post Exposure Protocol.”