2012 Spring Break International Service-Learning Engineering (ISLE) Trip Kimo, Peru March 8-17, 2012

The Carnegie Mellon University Mechanical Engineering Department is sponsoring an outreach trip to Kimo, Peru. We will be introducing engineering concepts to street children by working on hands-on projects with them. Additionally, we will be assisting in the maintenance of buildings at a boys home in Kimo. We will be working with a PCA (Presbyterian Church in America) church through Mission to the World (MTW). The trip is open to all Carnegie Mellon students, but only Mechanical Engineering undergraduate students are eligible for financial support from the Mechanical Engineering Department. There is no course credit (and no tuition) for the trip, but it will satisfy the study abroad requirement for the CIT Designated Minor in Global Engineering (GE) for CIT students. (Please see the following CIT internet site for the courses needed to satisfy the minor: http://www.cit.cmu.edu/current_students/services/majors_minors/engineering_minors/international.html). We will leave on March 8 and return on March 17. Students must travel with the CMU group from Pittsburgh to Peru and back to Pittsburgh. The total cost, including airfare, food, and housing will be about $2,250. MechE students requesting department support for the trip are asked to contribute $750 towards the cost of the trip and the department will pay the remainder. If you can contribute more, please do so. If you cannot afford $750, please see Professor Reid (MechE). The student contribution should be made payable to Mission to the World and is fully tax-deductible. In order to go, you must have a passport (valid at least 6 months beyond our stay) ready before departure (If you don't have one, it takes several weeks), health insurance that covers international travel, and an ISIC card (approximately $25). Before leaving, you should get a tetanus booster shot and follow the CDC guidelines for inoculations for rural areas of Peru in the Amazon jungle. In particular, you must have a vaccination for Yellow Fever and be able to provide written documentation. Yellow Fever vaccinations are currently in short supply, so please get one as soon as possible. You will be added to the list of people going on the trip when you: a) Bring a check payable to Mission to the World to Professor Reid (Scaife 415). b) Provide a copy of your passport. c) Fill out an MTW medical release form (see attached). d) Provide documentation of your Yellow Fever vaccination. e) Fill out the STO-IT Agreement and Personal Data Sheet forms from the CMUs study abroad office that you can download at: http://www.studentaffairs.cmu.edu/oie/sab/gettingstarted/stoit.html. f) Provide evidence that you have obtained an ISIC card. g) Provide Professor Reid with your cell phone number and birthdate. h) Give us your commitment that upon returning from the trip, you will fill out a survey and submit a quote regarding your experiences.

Engineers Creed
As a professional engineer, I dedicate my professional knowledge and skill to the advancement and betterment of human welfare. I pledge to give the utmost of performance, to participate in none but honest enterprise, to live and work according to the laws of man and the highest standards of professional conduct, to place service before profit, honor and understanding of the profession before personal advantage, and the public welfare above all considerations. In humility and with need for divine guidance, I make this pledge.
Adopted by the National Society of Professional Engineers, June 1954

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ADULT MTW Release Form

Participant please complete ALL information requested, give completed form to your team leader. Team Leader please review and sign each form; send copy to MTW and take original to the project.
Participant's Name: Date of Birth (mo/day/yr): Gender (male/female): Address: City, State, ZIP: Home Phone: Alternate Emergency Contact Name and Phone: Project Location: Project Dates: Church: Church City/State: Team Leader: Email:

PROJECT INSURANCE COVERAGE and REQUIREMENTS 1. WHAT WE PROVIDE MTW Short-term provides $75,000 Travel Medical Coverage for each participant. This includes emergency evacuation expenses when necessitated by circumstances occurring more than 50 miles from home. This coverage is provided for all participants in the short-term program and is included in the project cost. 2. WHAT WE REQUIRE MTWs project insurance acts as a secondary coverage. Each participant is required to have his/her own primary medical coverage. For international projects, the primary coverage must cover them while overseas. Any participant, who does not have a primary medical insurance policy, must apply for supplementary coverage. Recommendations have been provided to your team leader. Please indicate the status of your primary medical insurance: US projects: I do have a primary medical insurance policy. Insurance Company:_________________________ I do not have a primary medical insurance, but I am applying for supplementary coverage. International projects: I do have a primary medical insurance policy, and I have confirmed that it will cover me while outside the US on this project. Insurance Company:___________________________ I have primary medical insurance, but it will not cover me outside the US; I am applying for supplemental coverage. I do not have a primary medical insurance; I am applying for supplementary coverage.

RELEASE OF LIABILITY (US and international projects) I am aware of the inherent risks and dangers in traveling to and ministering in other countries and the potential risks to myself and my property as a result of participation in the project (including but not limited to illness, injury, acts of terrorism, death, robbery, kidnapping, or other loss or destruction of life or property). I fully assume these risks, understanding that MTW cannot be responsible for any personal loss or disaster that I may experience in connection with my volunteer ministry service to MTW. I hereby agree to waive and release any and all claims and causes of action for damages or other relief that I may have against MTW, the Presbyterian Church in America, my sending church/organization, any of their affiliated or member entities, and their respective officers, directors, employees, agents, attorneys, or representatives, based on my volunteer services for MTW. I acknowledge personal responsibility for my own actions outside the direction of ministry personnel, or the scope of this ministry project or program. I understand that this release of liability is effective only as it applies to, and as interpreted by the laws of the countries involved. Have you ever been accused or convicted of child sexual abuse? Signature of adult participant: 1 Yes No Date:

2012 MTW RELEASE FORM - ADULT PARTICIPANTS

MEDICAL HISTORY
As a project participant, you are asked to give the following health information, in order for the project leadership to be aware of any risk your participation may create. Project leaders are free to require a doctor's release statement if a serious health problem exists. Failure to provide known information will release both the team leader, Mission to the World, and project leaders from responsibility arising due to complications brought on by the activities of this project.

A. Please check any conditions for which you have been treated or seen a physician. Heart Trouble Kidney Stone or Infection Digestive / Intestinal Disorder Heart Murmur Bladder Stone or Infection Colitis Abnormal Pulse Gall Bladder Disease Ulcer Rheumatic Fever Internal Bleeding Gout Chest Pain Prostate Trouble Deformity / Amputation Stroke Sugar, Albumin, Blood or Pus in Urine Skin Disorder High Blood Pressure Psychiatric Problem Hernia Hardening of the Arteries Emotional/Nervous Problem Disease of Eyes Diabetes Epilepsy / Convulsion Disease of Ears Circulatory Disorder Other Nervous System Disorder Disease of the Nose / Throat Blood Disorder/Disease Cancer / Tumor Bronchitis Hepatitis Dizziness / Loss of Consciousness Tuberculosis Anemia Frequent Headaches Other Lung Disorder Thyroid/other Gland Problem Arthritis Asthma* Cirrhosis / Liver Trouble Sciatica Allergy - Recurring** Pregnant (currently): (Pregnant women are not permitted to participate on projects rated as Intermediate, Substantial or High Risk. Check with your Project Administrator if you are not sure of your project rating.)
*Some project locations are high altitude. Check with your project administrator if you are not sure of your project altitude.) ** If you are allergic to bee stings, please bring a current bee sting kit and/or prescription medication to the project.

B. Please explain any conditions listed above that you have been diagnosed with or treated for in the past five years. (Include date of last treatment or office visit for each item checked).

C. What medication, if any, will the participant be taking during the project (and for what purpose)?

D. IMMUNIZATIONS AND MEDICAL CONSENT 1. "I have had all routine immunizations, (dT-diphtheria, tetanus, MMR-measles, mumps, rubella, and polio)." ____ Yes ____ No 2. "I have had a tetanus booster within the past 10 years. ____ Yes ____ No, but I will have by the beginning of the project. 3. "I have checked with my doctor, the CDC or a travel clinic and am aware of the immunizations recommended and required for the area to which I will be traveling." ___Yes ___ No 4. "In the event of a medical emergency, I hereby consent to the necessary and proper treatment, surgery, and/or anesthetic by a licensed physician or health care professional."
Signature of adult participant: Date:

Form Reviewed by (Team Leader signature): 2

Date: