Himalayan HealthCare Fall 2023 Medical Dental Trek Application

Dear Volunteer,

As we enter our 30th year of operations, we are delighted that you will be participating in the Fall 2023 trek organized by Himalayan HealthCare. The trek dates are Nov 18 to Dec 4, beginning and ending in Kathmandu, and the full trek fee is $3,300.

In order to complete your registration we will need a few important items including:
1. Signed Legal Release and Discharge Form
2. Signed and completed Medical Questionnaire
3. Completed Medical Certificate signed by your physician
4. Current curriculum vitae or resume
5. Letter of recommendation from your current or most recent employer
6. Graduation and Post-graduate Certificates (for medical professionals)
7. Copy of your professional license (if applicable)
8. Letter of Good Standing from your state's Medical Board (if applicable)
9. Medical school transcripts (if applicable)
10. Copy of the inside cover of your passport
11. Scanned copy of passport photos
12. Deposit of $1,800
This application will walk you through the required steps and your information will be submitted through a secure, encrypted form.

If you have any questions about the application, please contact Anil Parajuli at anilhhc@gmail.com or Soni Parajuli at parajuli.soni@gmail.com.

Thank you for your interest in trekking with Himalayan HealthCare. We look forward to welcoming you in Nepal.

Sincerely,

Ashika Jain, M.D.
President, Board of Directors
Himalayan HealthCare Inc.
Himalayan HealthCare Fall 2023 Medical Dental Trek Application

18 November - 4 December
AGREEMENT FOR PARTICIPANTS RELEASE AND DISCHARGE | ACCEPTANCE OF RESPONSIBILITY AND ACKNOWLEDGMENT OF RISKS
Name*

First Name Last Name
E-mail*
Address*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Phone Number*

Area Code Phone Number
*

By checking this box and typing my name below, I, the above-named person, being above age eighteen, in consideration of the right to participate in Himalayan HealthCare's medical trek, hereby acknowledge, understand and agree with Himalayan HealthCare, Inc., and release and discharge Himalayan HealthCare, Inc., on behalf of myself, my heirs, assigns, personal representative and estate.
Full Name*

First Name Last Name
Date*

MonthDay Year
ACCEPTANCE OF RISK AND RESPONSIBILITY

Being aware that this medical trek entails risks of injury to myself and a risk of injury to third parties as a result of my actions, I agree and promise to accept and assume all responsibility and risk for injury, death, illness or disease, or damage to myself or to my property arising from my participation in this medical trek.

I am further aware that Nepal has experienced political instability from time to time, and that various governmental agencies and other organizations publish periodic updates on the situation as well as travel advisories for specific districts. I am aware of this situation, and also aware that certain of such organizations (including the US State Department) have recently issued a statement that Maoist groups in Nepal have threatened to take action against non-governmental organizations affiliated with other nations, including the United States.

I am informed about these risks and accept the possibility of political activity and/or physical harm due to political unrest. I acknowledge that Himalayan HealthCare reserves the right to make last-minute changes in trek locations, itineraries, or even to cancel a trek if deemed advisable in Himalayan HealthCare’s sole discretion.

I agree and promise to accept and assume all responsibility and risk for injury, death, illness or disease, or damage to third parties and their property arising from my participation in this medical trek.

My participation in this medical trek is purely voluntary; no one is forcing me to participate, and I elect to participate with full understanding of the potential risks.
*

By checking this box and entering my name below, I acknowledge that I have read, understand and agree to the terms above.
Full Name*

First Name Last Name
Today's Date*

MonthDay Year
RELEASE

I hereby voluntarily release and forever discharge Himalayan HealthCare, Inc., its agents or employees from any and all liability, claims, demands, actions or rights of action, which are related to, arise out of, or are in any way connected with my participation in this medical trek, including specifically but not limited to the negligent acts or omissions of Himalayan HealthCare, Inc., its agents or employees, and all other persons or entities, for any and all injury, death, illness or disease, and damage to myself, or damage to my property or to third parties.

I further agree and promise to hold harmless and indemnify Himalayan HealthCare, Inc., its agents or employees, from all defense costs, including attorney's fees, or from any other costs incurred in connection with claims for bodily injury or property damage which I may negligently or intentionally cause to third parties in the course of my participation in this event.

I further agree and promise not to sue, assert or otherwise maintain or assert any claim against Himalayan HealthCare, Inc., its agents or employees, for any injury, death, illness or disease, or damage to myself or damage to my property arising from or connected with my participation in this medical trek or from any claim asserted against me by third parties.
*

By checking this box and entering my name below, I acknowledge that I have read, understand and agree to the terms above.
Full Name*

First Name Last Name
Today's Date*

MonthDay Year
PARTICIPANT INSURANCE BENEFITS

I understand and acknowledge that Himalayan HealthCare, Inc. will not provide me with any insurance coverage benefits and that it is my responsibility to purchase adequate insurance.
*

By checking this box and entering my name below, I acknowledge that I have read, understand and agree to the terms above.
Full Name*

First Name Last Name
Today's Date*

MonthDay Year
PHOTO RELEASE

I hereby authorize and give full consent to Himalayan HealthCare, Inc. to copyright or use all photographs, slides and films in which I appear while participating in a medical trek sponsored by Himalayan HealthCare, Inc. I further agree that Himalayan HealthCare, Inc. may transfer, use or cause to be used these photographs, slides or films for any and all exhibitions, public displays, publications, commercials, art and advertising purposes without limitation or reservation.
*

By checking this box and entering my name below, I acknowledge that I have read, understand and agree to the terms above.
Full Name*

First Name Last Name
Today's Date*

MonthDay Year
*

By checking this box and typing my name below, I acknowledge that I have read this entire document, understand it completely, and agree to be bound by its terms. I am aware that I am giving up important legal rights I might have. I sign of my own free will.
Full Name*

First Name Last Name
Date*

MonthDay Year
MEDICAL QUESTIONNAIRE
This medical questionnaire is an important way we try to create a safe journey for you. Your trip will entail traveling into areas where medical facilities are nonexistent, and evacuation may be delayed for several days.

Many of our travelers have had a variety of medical conditions and have experienced no problems during the trip. Nevertheless, we must be aware of these conditions prior to your departure. Therefore, it is very important that you be very complete and candid in providing us with the requested information. We endeavor to prevent medical problems in the field and it is critical that our medical trek leaders possess all relevant medical history to manage a medical emergency.

FAILURE TO DISCLOSE SUCH INFORMATION COULD RESULT IN SERIOUS HARM TO YOU AND YOUR FELLOW MEDICAL TREK MEMBERS.

If we have any questions about your capability to complete the trip, we will call and discuss it with you and/or your doctor (with your permission). If we think you should not participate in the trip, we will refund all trip payments, except a $100 processing fee. Each trip participant is responsible for any medical expenses. We cannot refund the cost of medical examinations or other expenses you incur in preparing for your trip.

If you arrive with a preexisting condition or injury, which is not indicated, on your medical forms and you are subsequently forced to leave the trip because of this condition, you will be charged all extra evacuation expenses and will not receive a refund of any unused trip services.

If you check yes to any question below, please provide an explanation below.

Every item must be completed. Incomplete forms will not be accepted.

Your place on the trip you have selected will be confirmed when we receive all forms, filled out and signed. All medical information will be kept strictly confidential.
1. Do you have any existing medical problems?*

YesNo
If you answered Yes to Question 1, please explain.
2. Are you under the regular care of a physician?*

YesNo
If you answered Yes to Question 2, please explain.
3. Does your health prevent you from participating in any physical activities?*

YesNo
If you answered Yes to Question 3, please explain.
4. Are you taking any prescriptive medications regularly? Which ones and why?*

YesNo
If you answered Yes to Question 4, please explain.
5. Have you been hospitalized in the past five years?*

YesNo
If you answered Yes to Question 5, please explain.
6. Do you have any allergies or reactions to any medications, foods, insects or other agents? *

YesNo
If you answered Yes to Question 6, please explain.
7. Have you ever had any of the following? Please check all that apply.*

EpilepsyHeart DiseaseHepatitis or JaundiceFoot, Leg or Back ProblemsDiabetesLung DiseaseArthritisAltitude IllnessAsthmaHigh Blood PressureIntestinal ProblemsMental IllnessNone of the Above
If you checked any boxes in Question 7, please explain each in detail.
FILE UPLOADS
Please upload scanned copies of the front cover of your passport, professional license (if applicable), curriculum vitae, letter of recommendation from your current or most recent employer and completed doctors certificate signed by your physician. Your application will not be complete until we receive these items.
Letter of Recommendation
Scanned Copy of Passport Photos*
Curriculum Vitae
Professional License (if applicable)
Letter of Good Standing (for medical professionals)
Diploma and Post-graduate Certificates (if applicable)
Medical School Transcripts (if applicable)
Doctors Certificate*
TREK DEPOSIT
In order for your trek application to be considered, we must receive a deposit in the amount of $1,800. Please complete the below section in order to pay the deposit via PayPal.
Trek Deposit

prevnext( X )
USDTrek Deposit
*

I understand that my deposit of US$1,800 will be retained as a processing fee if I decide to cancel my participation prior to October 18, 2023. I also understand that if I cancel my participation any time after October 19, 2023, I will not be entitled to a refund.
Full Name*

First Name Last Name
Date*

MonthDay Year
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Himalayan HealthCare Fall 2023 Medical Dental Trek Application

AGREEMENT FOR PARTICIPANTS RELEASE AND DISCHARGE | ACCEPTANCE OF RESPONSIBILITY AND ACKNOWLEDGMENT OF RISKS

MEDICAL QUESTIONNAIRE

FILE UPLOADS

TREK DEPOSIT