Name *

First Name

Last Name

Phone

(###)

###

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Eligibility Assessment

If you do not meet any of the stipulations below please give more information in the box at the bottom of the form.

I understand that coverage is only included for the trip described above.

I hold professional qualifications for the practices which I seek coverage for

I confirm that I do not intend to treat any professional sports people or high profile participants unless acting in the capacity of a first responder in cases of an absolute emergency and all ongoing treatment thereafter is passed on to the appropriate treating physician or medical facility

I hold all client records for a minimum of 7 years or in line with industry standards and/or requirements

I have NOT been subject to any claims for negligence or breach of professional duty in the last 10 years

I am NOT aware of any shortcomings in my work that could lead to a claim against me. This includes a shortcoming which I cannot reasonably put right or a complaint about my work or anything I have supplied which cannot be immediately resolved

I am NOT aware of any loss from the suspected dishonesty or malice of any employee or self-employed freelancer

I have NEVER been declared bankrupt, insolvent or made arrangements with creditor either in a personal or in a business capacity

For any malpractice, public liability or errors and omissions insurance I have NEVER had a policy: cancelled, declined, renewal refused, had experience accepted with special terms

Endeavour Participation *

I agree to submit a short article (min 500words) for Endeavour Medical Education hub. This can be based around a case study or reflection, kit review, location write up, or educational piece on management of a condition on expedition.

I have been a participant on an Endeavour Medical course or expedition

I have previously worked with Endeavour Medical in a teaching or consultancy capacity