1. Name of overseas receiving organization/institution: *

2. Contact person: *

3. Address: *

4. City/Region: *

5. Country: *

6. Phone:

7. Email:

8. Website:

1. Organization name: *

2. Contact person: *

3. Address: *

4. City/Region: *

5. State: *

6. Zip Code: *

7. Phone: *

8. Fax:

9. Email:

10. Website:

11. How did you hear about MedWish:

1. Name and contact information for medical professional responsible for creating supply wish list:

2. How will the supplies be transported?:

3. Who is responsible for shipping arrangements and associated costs?:

4. Departure date: JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember1234567891011121314151617181920212223242526272829303120092010201120122013201420152016201720182019202020212022202320242025202620272028
5. Return date: JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember1234567891011121314151617181920212223242526272829303120092010201120122013201420152016201720182019202020212022202320242025202620272028
6. Maximum weight or volume of supplies:

7. Briefly describe the nature of your trip:

1. Please explain in detail why the donated supplies and equipment are needed by the hospital. Please also include how the donation from MedWish International will be used and who will use and benefit from this donation.

2. Please list any restrictions on supplies taken from medwish due to their expiration date, sterility, size, weight, or any other reasons.

3. Provide a specific list of supplies and equipment needed:

The medical supplies, equipment and materials available from MedWish International are items that would otherwise be discarded from healthcare facilities and/or providers 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.

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 and 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.

Name: *

Name of organization: *

Please enter your email address here if you would like to receive a copy of this form via email:

* I agree to the above terms and agreements