Name *

As it appears on your passport (please include middle names if listed)

First Name

Last Name

Birthday *

MM

DD

YYYY

Address *

No PO boxes

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

One we can reach you at outside the USA

Country

(###)

###

####

Passport Expiration Date *

Must be good until 5/11/2020

MM

DD

YYYY

Emergency contact Phone # *

Country

(###)

###

####

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.

Acknowledment *

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 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.

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 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.

Vaccinations *

By checking this box I acknowledge that I have reviewed the required vaccinations for the destination country, and have either obtain the recommended vaccines or have foregone their administration and therefore have accepted the risk of contracting preventable diseases. I alone accept responsibility for this decision, and in no way will hold Nursing Beyond Borders responsible for this decision.

Photos *

By checking this box I agree to provide Nursing Beyond Borders with photos of my impact on the mission. I acknowledge that the local NGO may not allow photos without written consent, and if this is the case I agree to obtain consent for the photos. 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 purposes.