Forms and Agreements

      As a volunteer participating in the Humanitarian Medical Outreach program, you will be required to sign an “Assumption of Risk and Hold Harmless Agreement.” There will also be another document that you must sign stating that you have a health insurance policy that will cover you while in Kenya. You will also be required to show verification of emergency evacuation insurance. Please let us know if you need any help with arranging the purchase of any of the above said insurance. This list is by no means exhaustive. Please feel free to ask us as many questions as you have. And if any of your family members have questions and/or concerns, please tell them to feel free to contact us also.

Humanitarian Medical Outreach Summer Service Trip

Assumption of Risk and Hold Harmless Agreement

(draft)

General Statement:

Humanitarian Medical Outreach provides a rare opportunity for student from Rice University to work hand in hand with students from other institutions around the country and with a grass-roots NGO in Kenya. Participation in the Summer Service Trip can be expected to enhance one’s understanding of the history, culture, and values of the people of the Western Province of Kenya, as well as various healthcare-related issues. The participating volunteer is offered an exciting, rewarding, and culturally enriching experience. 

The participating volunteer must understand, however, that there are certain health and safety risks associated with participation in the Summer Service Trip. Volunteers live in the Western Province of Kenya, in housing arranged by the Executive Director of the Kenyan non-governmental organization Inter-Community Development Involvement (ICODEI), Reverend Reuben Lubanga The homestead of Reverend Lubanga is pleasant, but geographically isolated, with no electricity, running water, telephones, or other modern facilities. Living accommodations are provided in mud or cement homes that are owned and supervised by Reverend Lubanga.

Under these circumstances, Humanitarian Medical Outreach has no direct control over the participant’s travel and living or working environment. By signing this agreement, the participating volunteer agrees, among other things, that he or she assumes the risks of, and responsibilities for (1) damage to or loss of the volunteer’s property, and (2) bodily injury, illness, or death, where that damage, loss, injury, illness or death results from the volunteer’s participation in the Summer Service Trip. 

Assumption of Risk:

I, the undersigned volunteer, wish to participate in the Humanitarian Medical Outreach Summer Service Trip. My participation is completely voluntary.  I understand that there certain risks, including, but not limited to:  (1) robbery, rape, murder, or vehicle accidents, (2) property loss or damage, (3) catastrophic injury or death, (4) illness or death from tropical diseases, such as malaria, yellow fever, HIV/AIDS, Ebola, tuberculosis, meningitis, diarrhea, Rift Valley fever, dengue, cholera, typhoid, schistosomiasis, hepatitis, bacterial infection, extreme heat, etc.  I further understand that Humanitarian Medical Outreach has no ability to control my living or working environment during the period of time that I volunteer in Kenya.  In light of these understandings, and in consideration of my participation in the Summer Service Trip, I hereby personally assume these risks, whether foreseen or unforeseen, that arise from, or are in any way connected with, my participation in the Summer Service Trip.       

Release and Hold Harmless Agreement:

In further consideration of my participation in the Summer Service Trip, I, the undersigned student, agree to release Humanitarian Medical Outreach, its fiscal agent, officers, sponsor and members from any and all liability and responsibility for any damages resulting from (1) robbery, rape, murder, or vehicle accidents, (2) property loss or damage, (3) catastrophic injury or death, (4) illness or death from tropical diseases, such as malaria, yellow fever, HIV/AIDS, Ebola, tuberculosis, meningitis, diarrhea, Rift Valley fever, dengue, cholera, typhoid, schistosomiasis, hepatitis, bacterial infection, extreme heat, etc., whether foreseen or unforeseen, that I may sustain as a result of my participation in the Summer Service Trip.  I also agree to indemnify, save, and hold harmless Humanitarian Medical Outreach and all of its agents, officers, sponsors and members from any and all claims, demands, actions, or causes of action brought by third parties where those claims, demands, actions, or causes of action arise out of my activities as a participant in the Summer Service Trip.

I certify that I am eighteen years of age or older, that I have read and understood the foregoing, that I have been given an opportunity to confer with counsel of my choosing concerning the foregoing, and that I execute this agreement voluntarily and consideration for my participation in the Summer Service Trip described herein.

Volunteer’s Name (Printed): __________________________________________________

Signature:  __________________________________________________________________

Witness: ___________________________________________________________________

Date: ______________________________________________________________________

___________________________________________________________________________

Emergency Contact:

Name: _______________________________________________________________

Relation: _____________________________________________________________

Phone (Work and home): ________________________________________________

Address: _____________________________________________________________

Humanitarian Medical Outreach Summer Service Trip

Proof of Health Insurance Agreement

(draft)

As a participant in the Humanitarian Medical Outreach Summer Service Trip, you will need to be enrolled in a health insurance plan that will cover you during your time in Kenya, as well as any other countries that you may choose to visit during the summer of 2002.

International Medical Group, Inc. offers comprehensive medical coverage for US Citizens traveling abroad from 15 days to one year.  The Patriot International plan provides worldwide coverage and the choice to seek treatment anywhere in the world except the United States. Emergency Evacuation, Repatriation, Emergency Reunion and Accidental Death & Dismemberment are included in the plan.  To purchase this policy or resolve any questions, please call 1-800-786-5566 and ask for the travel department.

________        No, I do not plan on purchasing the medical insurance from International Medical Group, Inc.  I have consulted my health care provider and am covered under my current health insurance policy.

________        Yes, I plan on purchasing the medical insurance from International Medical Group, Inc.   I have consulted my health care provider and I am NOT covered under my current health insurance policy.

I certify that I am eighteen years of age or older, that I have read and understood the foregoing, that I have been given an opportunity to confer with counsel of my choosing concerning the foregoing, and that I execute this agreement voluntarily and consideration for my participation in the Summer Service Trip described herein.

Student’s Name (Printed) ______________________________________________________

Signature:  __________________________________________________________________

Date: ______________________________________________________________________