Dominican Republic´s Trip Application Form.

Major José Jamil Miranda

Educational Grant Application

APPLICATION DEADLINE: SEE www.joseshands.com/the-grant

Thank you for your interest in Jose’s Hands. Please visit us at www.joseshands.org for more information about our commitment to subsidizing the cost of first-year medical school students to go on medical-service missions serving underserved or underrepresented communities in the United States or abroad.

Student Applicant’s Name (Last, First, Middle):      

Date of Birth (mm/dd/yyyy):                  Age:             Sex:      

Address:      

City, State, Zip Code:      

Email Address:      

Telephone Numbers:  Home of Record:        Cell:      

Medical Mission Trip(s) for Which Applying:      

Part A – About the Grant

Please consider and review the following before completing the application:

  • Trip Details: Please read and review the trip details on the previous page. Know and understand every component.
  • After Your Trip: On completion of your trip, you are required to provide a written summary of your experience along with some photographs of yourself “in action.” The report should be brief and will be considered for publication, in part or whole, in the “Jose’s Hands Yearbook,” the book and newsletter of Jose’s Hands on our Website.
  • Disclaimer: The student is traveling at his/her own risk. The student is responsible for obtaining medical and life insurance. Neither Jose’s Hands, Inc. nor its board of directors is responsible for any loss or damage of life or property related to the student’s participation on the medical mission. Emmaus Medical Mission (EMM), its directors, board of directors, partners, and supporters are NOT responsible for any sickness, injury, or even loss of life as a result of your involvement in the trip. You participate as a personal choice taking and accepting all possible risks involved.
  • Point of Contact: Please contact José E. Miranda at (305) 788-7560 or info@joseshands.org for questions about this grant application or educational grant opportunities with Jose’s Hands. (Do not contact the mission trip’s hosting organization for questions about this grant application. Mr. Miranda will put grant recipients in contact with the hosting organization, which will provide additional travel and mission information.)

Part B – About You

  1. How did you hear about Jose’s Hands?
  1. Describe your work or volunteer experience that has focused on serving underrepresented or underserved communities in the United States or abroad.
  1. What are the primary goals that you hope to achieve for your chosen medical mission project?
  1. What are your reasons for wanting to volunteer on a medical mission project?
  1. Explain how your professional education, work experiences, volunteer experiences, and personal skills will benefit you and those you will serve on the medical mission project.
  1. Explain how you will evaluate your project’s success, including performance of specific goals and other results you hope to achieve.

Part C – Medical School Information

Name of Medical School:      

Address of Medical School:      

City, State, and Zip Code      

Name of Dean of Students:      

Telephone Number of Dean of Students:      

Part D – Emergency Contact Information

Name:      

Address:      

City, State, and Zip Code      

Telephone Number:      

Part E – Three Non-Blood-Related References

1.Name:                                                                            2. Name:      

Address:                                                                       Address:      

City, State, Zip Code                                                    City, State, Zip Code      

Email Address:                                                             Email Address:      

Telephone Number:                                                     Telephone Number:      

3.Name:

Address:      

City, State, Zip Code      

Email Address:      

Telephone Number:      

Part F – Grant Application Instructions

  1. Prepare an application packet consisting of the following:
    1. Completed Jose’s Hands Educational Grant Application
    2. Signed Jose’s Hands Educational Grant Affidavit (complete, print, sign, and scan)
    3. One-page résumé
  1. Submit the packet to José E. Miranda by the deadline by ONE of the following methods:
  1. Email to emilio@joseshands.org
  1. Mail to

MAJOR JOSE JAMIL MIRANDA

EDUCATIONAL GRANT

7854 NW 188TH LN

HIALEAH FL  33015-5267

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