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Highland Support Project Serving Mayan Communities of Guatemala APPLICATION Midwifery & Health in the Americas: Marrying Mayan & Western Medicine Service-Exchange Program – August 2 – 9, 2014 Hosted by the VCU Institute for Women’s Health, and the Highland Support Project, Partners in Service Program Name: __________________________________________(exactly as it appears on your passport) Date/Year of Birth ________________________________________________________________________ Address: ___________________________________________________________________________ Daytime phone: _________________________________ Evening or cell phone: _________________ E-mail address: _____________________________________ Occupation: ________________________________________ Passport number: _______________________________ Nationality: _____________________ Passport expiration date: ___________________________________ How did you learn about the program? Please share why you would like to participate in this program? Have you had any previous international experience? If yes, please detail. Please tell us about any relevant experience in Guatemala or elsewhere in Latin America, and/or with women’s health, maternal and/or child health? 1 Do you have any personal objectives and expectations for this trip? Detail any other jobs, experiences, or qualifications that you believe would be relevant. Do you have any preliminary ideas on knowledge, skills or an activity you would like to share with the Mayan midwives and/or health promoters we spend time with? How do you anticipate using this experience in the future when you return to your community? Please rate your language proficiency (circle one): Spoken Spanish: fluent good fair poor Written Spanish: fluent good fair poor none none Note: We will be ‘living’ and working in Quetzaltenango which is located in a mountain valley at an elevation of about 7,655 ft. Some short term hiking may be involved and it often rains a lot at this time of the year. If you have any health concerns or physical limitations related to these conditions please note above. Do you have any health conditions that might be a concern while traveling? ____ YES ____NO IF YES PLEASE EXPLAIN: I am interested in having HSP purchase a ticket for me as part of the group Yes _______ No _______ (More info will be provided as soon as we get all the flight purchase decisions) 2 _________________________________________________________________________________ PLEASE RETURN THE ABOVE 2 PAGE APPLICATION FORM by April 25, 2014 Send to Janett Forte, by e-mail to: [email protected] or by fax to (804) 827- 0957 or by mail to: Institute for Women’s Health, PO Box 980319, Richmond, VA 23298-0319 If selected, a non-refundable deposit of $250 is due by May 2, 2014 The total cost of the exchange is $985.00 per person to cover coordination, logistics, food, lodging, in-country transportation, cultural activities and language translation. Trip emergency medical, evacuation, and liability insurance is also included. The deposit will be included in this cost. We kindly ask that participants pay in full by July 2, 2014 For questions or clarifications, please contact Janett Forte, [email protected] or at (804) 827-1200 Notices of application acceptance will be sent by April 30, 2014 Some Preliminary Logistics – FYI Trip Details: The standard 8 day trip with all expenses paid includes all in country transportation, food, lodging cultural activities and translators. The cost is $985.00 plus airfare, which is usually about $600.00. This fee also covers the cost of the emergency medical, evacuation, and liability insurance policy that covers every traveler on the trip. Airfare: There are a few options for purchasing airfare for your service trip. HSP is more than happy to find and purchase airfare for the team, or individual team members may purchase their own tickets. If team members are purchasing their own airfare, it is ideal that all team members travel on the same flight, and HSP can facilitate communication between team members regarding available flights and travel options. It is IMPERATIVE that team members arrive in Guatemala NO LATER THAN 2:00 pm! This is required to ensure the safety of the team as they travel out of Guatemala City. If HSP is purchasing airfare for the team, airfare will be purchased after team members remit an airfare deposit, typically included with the 2nd trip payment. HSP will not purchase a plane ticket before payment has been received. Once tickets are purchased, the team members for whom the tickets are purchased are responsible for any additional airfare related costs needed, including, but not limited to, baggage fees and ticket changes. The round trip cost is around $600. We will search for the best price and travel logistics. Flights are generally out of the Washington DC area – either DCA or IAD airports. HSP can purchase your airfare out of Richmond, but this usually costs more. Trip Planning Meetings: Information Session: A pre-trip planning meeting will be hosted by Janett Forte in late June or early July at the Institute for Women’s Health. We will have a chance to begin to build our team - sharing ideas and interests. At the meeting we will provide more information on the context for women’s health in Guatemala, including some history on health related trips and health initiatives in Guatemala. We will provide updates on trip logistics, completion of paperwork, and encourage input for our in-country project itinerary. We’ll address any questions related to final logistics, packing recommendations etc. 3 Trip Timeline and deadlines ALL APPLICATIONS ARE DUE by April 25, 2014 Notices of application acceptance will be sent by April 30, 2014 Payment Schedule The total payment for the trip is $985.00. Your program fees cover food, lodging, interpretation, meeting facilitation, and transportation within Guatemala. This fee also covers the cost of the emergency medical, evacuation, and liability insurance policy that covers every traveler on the trip. Deadlines - The trip is scheduled for Saturday August 2 to Saturday August 9, 2014 A non-refundable deposit of $250 is due by due by May 2, 2014 May 27, 2014 –notify us of your decision about purchasing airline tickets. May 30 2014 - purchase your own air fare deadline – send us your flight details. June 6, 2014 - Second Payment of $367.50 and airfare*(about $600.00) due. (Generally the earlier we purchase tickets for the group– the better the price) If HSP is purchasing your airfare and the true ticket cost is different from the $600 estimate, the final payment will be adjusted to reflect the difference in cost. If you’re purchasing your own airfare, your 2nd payment will not include airfare cost and is then ($367.50) 30 days before departure date = July 2, 2014 Remaining balance of payment due ($367.50) or the difference based on adjustment for airfare cost for those that had HSP purchase tickets Saturday, August 2, 2013 – on our way – Depart for Guatemala ********* Checks are made payable to Highland Support Project and need to be mailed to HSP c/o Rachel Triplett - PO Box 7185 Richmond, VA 23221 or dropped off to Rachel at the HSP office 700 W. Franklin Street, Richmond. Call ahead Rachel’s cell # is 241-2881 1-16-14 (jf) 4