Name *

Please write name as it appears on passport. We will use this for booking travel. Include middle name(s) with first name field!

First Name

Last Name

Address *

No P.O. Boxes

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone 1 *

(###)

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Passport Expiration Date *

MM

DD

YYYY

Emergency Contact *

First Name

Last Name

Emergency Contact Phone *

Country

(###)

###

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License Standing *

By checking this box I agree that I am authorized to practice as a licensed nurse in the United States, and that my current nursing license is not only active but also has no disciplinary action against it.

Acknowledgement *

By checking this box I agree that I have read the mission acceptance email and associated attachments, and I intend to adhere to all deadlines, rules, and policies set forth in the email and attachments.

Deposit *

By checking this box I acknowledge that any deposit made to Nursing Beyond Borders either by myself or by another individual, group, or organization on my behalf is non-refundable, and I waive my right to that deposit, and any travel credits associated with the deposit or mission trip.

Vaccinations *

By checking this box I acknowledge that I have reviewed the required vaccinations for the destination country, and have either obtain or will obtain prior to departure the recommended vaccines for the host country. Including being fully vaccinated against Covid-19 (as defined by the CDC). I acknowledge documentation will be required prior to departure.

Medical and Evacuation Insurance *

By checking this box I acknowledge that I have either obtained medical and evacuation insurance that is valid in the destination country, or have foregone obtaining these insurance(s) acknowledging any medical expenses or cost associated with evacuation from the host country are solely my responsibility. I agree to release Nursing Beyond Borders from any medical or evacuation reimbursement claims that I may incur while on the mission trip.

Photos *

By checking this box I agree to provide Nursing Beyond Borders with pictures on a weekly basis of my impact on the project. I acknowledge that the NGO may only let me do this with their written consent, and I agree to obtain that consent if this is the case. I authorize Nursing Beyond Borders to use any pictures I take and/or any pictures that I appear in on their website, social media platform(s), and/or for fundraising/sponsorship/grant purposes.

Reimbursement *

By checking this box I acknowledge that Nursing Beyond Borders is subsidizing my trip. If for any reason I am not able to make the flight to the mission site, or perform my duties while on the mission site I agree to reimburse the out of pocket expenses minus my deposit amount incurred by Nursing Beyond Borders on my behalf. This includes costs such as flight, accommodation, baggage fees, volunteer supplies, transportation. (Ex: Deposit from volunteer: $1200, Total cost for 1 volunteer on trip $2000. If Volunteer is unable to make it to the mission the amount the volunteer would need to reimburse NBB is $800.)

PayPal account and volunteer reimbursement *

I acknowledge that I will need to pay the providers for their services to the children at the time of service. I acknowledge that these expenses will be 100% reimbursed by NBB. I agree to open and activate a PayPal account and submit receipts to NBB for reimbursement of these funds to an account I have access to in the host country. A picture of the receipts is a sufficient form of submission. If I choose not to open a PayPal account I acknowledge that I may submit the receipts to NBB upon my return for reimbursement by check for those cost associated with provider follow-up. I acknowledge that I must have at least an extra $400 in my ATM account all of which is available for use to provide healthcare for the children I see.

Database *

I acknowledge that a Google Sheets database is used to keep track of all my assessment and follow-up data I obtain on the children I see in the host country. By checking this box I agree to protect the privacy of those children listed in the database. I also agree to keep the database updated and acknowledge this as one of my important duties of the trip as it allows future volunteers to pick up where I left off. I acknowledge that without appropriate record keeping much of my work will result in unnecessary resources being spent on future trips to the project site.