Application form

Section 3: Project Narrative
How did you hear about MedWish?*

I have requested supplies from MedWish beforeInternet searchI was referred by someoneOther
If you were referred to MedWish by a person or organization, please let us know who:
Organizational Information

Please describe the mission, history and programs of the recipient organization. Include information about the organization’s structure, staff and patient/client numbers.
Mission and History (limit 750 words)*
Programs Offered - Please include any specialized departments offered to patients (i.e. oncology, pediatrics, ER, etc.) (limit 750 words)*
Approximate number of staff*
Number of Exam Rooms*
Number of Beds*
Approximate number of patients served annually*
Description of Need

Please describe the community or population the recipient organization serves, including leading health issues or diseases that are treated, data on poverty, conflict or disaster, and other information relevant to your program or project.
Need description: (limit 750 words)*

0/750
Medical Culture: Are there any culturally specific medical practices in this location that differe from western medicine? (i.e. women traditionally give birth standing versus in beds, etc.) (limit 750 words)*

0/750
Description of Project Goals

What are the short and long-term goals of the recipient organization? How will the requested supplies and equipment support these goals?
Short and long term goals (limit 750 words)*

0/750

Section 5: Reporting Responsibility

Feedback is a vital element of the Humanitarian Aid program at MedWish. It allows us to continually improve our services and programs to better support health care in developing countries. It also helps us secure continued financial support, donated supplies and volunteers.

A feedback survey (click here for sample) will be due back to MedWish within 60 days of your successful receipt of your shipment. Please complete the following form so that we can notify the responsible person to remind them.

By submitting this application, you consent to permitting MedWish to track and share information about the recipient organization and the sponsor organization for quality improvement, communications and fundraising purposes. Information included in the application as well as in the 60-day feedback report may be used for these purposes. You also agree that you will provide the feedback as requested below once a shipment is successfully completed.

If for any reason your organization cannot consent to publicizing details about your project please explain below. MedWish does not wish to put any recipients at risk and will respect confidentiality requests; however, we will require feedback from all recipients for internal record-keeping and quality improvement.

Please note: Failure to send complete and timely feedback report may disqualify the recipient organization from future shipments.
If any part of your project narrative cannot be shared publicly, please explain. (Contact information will never be sold/shared/publicly posted.)
Remember: Feedback is required for all shipments. We will honor confidentiality requests.
Who will be responsible for completing the feedback report?*

Recipient organization contact listed in Section 1Sponsor organization contact listed in Section 2Other
Name*

First NameLast Name
Organization & Title*
Phone Number*
Email Address*
Relationship to Project*

Section 6: Signature and Liability Release

Legal Statement

The medical supplies, equipment and materials available from MedWish International are items that would otherwise be discarded by healthcare facilities, individuals, and/or manufacturers in the United States. These materials are being made available strictly on an "as is" basis for the use by humanitarian relief organizations providing medical care in the developing world. MedWish International and the donor facilities do not represent, warrant or imply that such materials are fit, appropriate, and free of defects, sterile, pure or suitable for any purpose. Supplies from MedWish may not be exchanged for money, property, or services.

Each recipient organization and recipient facility assumes full responsibility for making an independent determination of the appropriateness of each item of donation before using it. By submitting an application for the receipt of donated supplies, each organization and recipient facility releases MedWish International, its officers, trustees, employees and donors from all responsibility, claims, costs and liability associated with the donated materials.

I have read and understand the above statement releasing MedWish International, its officers, trustees, employees and donors from all responsibility, claims, costs and liability associated with the donated materials.

Submission of this form is an agreement of the above terms, however, you may be asked to fax/mail a signed copy of this agreement in the future.

Additionally, by checking the box below, you confirm that you/your organization will not provide donated goods to any of the restricted entities, persons, or organizations published by any member state of the European Union, the United States of America government, the United Nations, or other Governmental Authority, including the U.S. Treasury Department’s List of Specially Designated Nationals and Blocked Persons, Sectoral Sanctions Identifications List, and Foreign Sanctions Evaders List, the U.S. Commerce Department’s Entity List, Denied Persons List, and Unverified List, the U.S. State Department’s nonproliferation lists, and the EU’s Consolidated List of Designated Persons, (collectively, the "Sanctions Lists"), or are owned or controlled by a person or entity which is included on such Sanctions Lists.
Acknowledgement*

I have read and understand this statement
Full Name*

First NameLast Name
Email address to send application summary for your records*
example@example.com
Date of Birth*

MonthDayYear
Today's Date*

MonthDayYear
Should be Empty:

	Yes	No	Not sure
Reliable electricity
Reliable, clean water
Dedicated storage space for the capacity of your shipment
Sterilization/Autoclave Capabilities
Oxygen
Nitrogen
Waste Disposal
Internet/Wifi Capabilities
Reagents & consumables for request equipment

	Yes	No	Not sure
Transportation capabilities to facility
Customs
Import laws for receiving country
Ministry of Health rules and regulations
Freight Forwarder (provide details below)

MedWish International Humanitarian Aid Application