Application for Returning Team Members AppForm v2.0 – November 9, 2021ARE YOU A RETURNING VOLUNTEER?(Required) First time team member this calendar year Returning team member this calendar year1. AFFIRMATION(Required) I hereby acknowledge I have read all the above Blanca’s House policies. You must open and read all policies otherwise your application cannot be submitted.Name of Team Coordinator who approved your attendance for this mission:(Required)What mission are you attending?(Required) Feb 7 – 12, 2022: General Surgery – Guayaquil, ECPersonal InformationPlease enter your name as it appears on your passport:Legal Name(Required) First Middle Last Suffix Gender Male FemalePreferred NameDate of Birth(Required) Month Day YearEmail(Required) Enter Email Confirm Email Name of spouse, parent/legal guardian, JV under 18 yrs. old, if attending missionRelationshipName Add Remove Click on the (+) sign if you have multiple people attending mission.Permanent Address(Required) Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Cell Phone(Required)Home PhoneCheck if mailing address is different from permanent address Yes Please give your current address for all correspondence, if different from above.Current Mailing Address Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Current mailing address phoneCurrent mailing address valid from MM slash DD slash YYYY Current mailing address valid until MM slash DD slash YYYY T-shirt Size(Required)X-SmallSmallMediumLargeXLXXLMeal Preference(Required) Non-vegetarian VegetarianRooming Preferences (there is an upcharge for a single room)(Required)SingleDoubleIf you select a double room and do not have a roommate, we will try to accommodate your rooming preference. However, we cannot guarantee there will be another team member available to share accommodations. Therefore, please be prepared to pay the single room rate if this situation occurs. Roommate (if requesting double occupancy)Attach a color copy of your signed Passport:(Required)Accepted file types: gif, png, jpg, jpeg, pdf, doc, docx, tif, tiff, Max. file size: 128 MB.IMPORTANT: Your passport must expire a minimum of 6 months after return date from mission. If you do not have a current passport please contact info@blancashouse.com immediately. [ Non-Medical Team Member ] I am a non-medical team member.If you are a non-medical team member, upload your resume.(Required)Accepted file types: pdf, doc, docx, xls, xlsx, Max. file size: 128 MB.Attach a copy of your SIGNED Medical License:(Required)Accepted file types: gif, png, jpg, jpeg, pdf, doc, docx, tif, tiff, Max. file size: 128 MB.IMPORTANT: Your SIGNED Medical License must not expire prior to the mission return date – please check that you have signed your license and confirm your expiration date prior to uploading. Attach a color copy of your Medical Diploma indicating your medical specialty. (Must be a clear copy: no flash, no fingers, no frames).(Required)Accepted file types: gif, png, jpg, jpeg, pdf, doc, docx, tif, tiff, Max. file size: 128 MB.Attach a color copy of your University Diploma.(Required)Accepted file types: gif, png, jpg, jpeg, pdf, doc, docx, tif, tiff, Max. file size: 128 MB.Medical HistoryEMERGENCY CONTACTSEmergency Contact – Name(Required)Emergency Contact – Phone(Required)Add second contact? YesEmergency Contact – Name #2(Required)Emergency Contact – Phone #2MEDICAL INFORMATIONAllergies(Required)Significant Medical Problems(Required)MEDICATIONS(Required)DrugDoseFrequency Add RemovePhysician Name(Required)Physician Phone(Required)CERTIFIED TRUE AND COMPLETE By checking this box and typing my name below, I certify that the facts set forth on the application form are true and complete.TEAM MEMBER APPLICATION AGREEMENT FORMName(Required)RELEASE FROM LIABILITY FOR BLANCA’S HOUSE CORPORATION: Please fill out the form below in its entirety.Location of Mission(Required)Hereby release Blanca’s House Corporation, its agents, representatives, directors, employees, contractors, insurers, and members from any and all responsibility and liability involving arising out of, or related to the planned medical mission scheduled to:From(Required) MM slash DD slash YYYY Start date of missionTo(Required) MM slash DD slash YYYY End date of missioninclusive (without limitation liability regarding my health or safety or my property).Type your Initials(Required)Date(Required) MM slash DD slash YYYY ACKNOWLEDGEMENT FORM1. IMMUNIZATION RESPONSIBILITY:(Required) I hereby take full responsibility for obtaining all my immunization at my own expenses.2. APPLICATION DEPOSIT(Required) Agree to non-refundable deposit of $500 partial payment. This amount is subtracted from the total cost of the mission.3. Payment Agreement(Required) Credit Card Transaction Fee AgreementWhen paying for trip costs with your credit card, Blanca’s House is assessed transaction fees for nonprofit organizations. During these challenging economic times, Blanca’s House is unable to absorb these charges any longer. We are including the 3.25% fee in your transaction for this charge.Mission Deposit Fee Price: 3.25% Transaction Fee Price: $0.00 Total Amount Late Fee Agreement(Required) I AgreeAll mission paperwork and money will be due by the dates indicated for each specific mission. After that time, an administrative fee of $250.00 will be assessed. The cost of mailing all the necessary documents to our host country is expensive. Blanca’s House cannot absorb the additional expenses of processing late submissions.4. TRAVEL ACKNOWLEDGEMENT(Required) By checking this box and typing my name below, I acknowledge that I understand and accept all of the above listed on this document.Name(Required)Date(Required) MM slash DD slash YYYY Parent's Name (If applicable)Date MM slash DD slash YYYY Credit Card(Required)American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Expiration Date Month Month010203040506070809101112 Year Year20222023202420252026202720282029203020312032203320342035203620372038203920402041 Security Code Cardholder Name Protected by reCAPTCHAIf you have any questions or need additional information, please contact Blanca’s House at info@blancashouse.com. Please only press the SUBMIT button once, it may take a few moments to process your application. EmailThis field is for validation purposes and should be left unchanged.
