Need help?
Step: 1 / 12
Contact information
Step: 2 / 12

APPLICANT

e.g.: H4B 1T2
e.g.: 514-444-5555
e.g.: 514-444-5555
e.g.: 514-444-5555
e.g.: 514-444-5555
Humanitarian Medical Kits Request
Step: 3 / 12

 

Request

Requests for more than one kits may require additional delivery time. It is strongly recommended that requests for kits be made at least 3 weeks prior to date of departure overseas.


Carriers
Step: 4 / 12

CARRIER

Additional carriers specified on next page

e.g.: H4B 1T2
e.g.: 514-444-5555
e.g.: 514-444-5555
e.g.: 514-444-5555
e.g.: 514-444-5555
Shipping information
Step: 5 / 12

 

SHIP TO ADDRESS

e.g.: H4B 1T2
e.g.: 514-444-5555

(Someone must be available to receive and sign for the kit when delivered.)

ADDITIONAL SHIP TO ADDRESS

e.g.: H4B 1T2
e.g.: 514-444-5555

(Someone must be available to receive and sign for the kit when delivered.)

ADDITIONAL SHIP TO ADDRESS

e.g.: H4B 1T2
e.g.: 514-444-5555

(Someone must be available to receive and sign for the kit when delivered.)

ADDITIONAL SHIP TO ADDRESS

e.g.: H4B 1T2
e.g.: 514-444-5555

(Someone must be available to receive and sign for the kit when delivered.)

ADDITIONAL SHIP TO ADDRESS

e.g.: H4B 1T2
e.g.: 514-444-5555

(Someone must be available to receive and sign for the kit when delivered.)

Travel Information
Step: 6 / 12

 

YES NO
** Please be advised that your kits(s) will be delivered approximately 2-3 days prior to your departure date unless otherwise pre-arranged.
Organization/NGO Affiliation
Step: 7 / 12

 

e.g.: 514-444-5555
e.g.: 514-444-5555

ORGANIZATIONAL ENDORSEMENT REQUIRED:

The Humanitarian Medical Kit(s) must be checked in at Canadian customs and travel to final destination without layover in another country.

Customs Information
Step: 8 / 12

 

Applicant/carrier must fully investigate customs procedures and adhere to policies of the country of destination to ensure safe passage through customs. HPIC is not responsible for customs clearance, foreign customs charges or taxes.

The kits(s) must be checked in at Canadian customs and travel to final destination without layover in another country.

Project Information
Step: 9 / 12

 

HPIC is diligent in following where our medicines/supplies are distributed and how people are being treated and healed. We require details about your upcoming project to enable us to serve you better and share our partnership with others. We expect to receive your Report, and photos, upon completion of your mission.

Healthcare Professional Endorsement
Step: 10 / 12

 

The medicines and medical supplies provided in the kit include prescription products, therefore, a physician or dentist currently licensed in Canada (who knows the carrier) is required to sign the following endorsement. A photocopy of current year's provincial license must be included.

e.g.: H4B 1T2
e.g.: 514-444-5555
e.g.: 514-444-5555
e.g.: 514-444-5555
e.g.: 514-444-5555
Please note that upon completion of this form, an email will be sent to the physician specified in this form asking him/her to review the application. Please ensure that the information above is correct.
Review
Step: 11 / 12

 

Please take a quick moment to review your answers.

Applicant / Carrier(s) Responsibilities
Step: 12 / 12

 

The undersigned applicant accepts the following conditions and agrees to implement them or ensure that they are implemented:

  • Medicines and medical supplies must be used outside North America and only in developing countries for humanitarian purposes;
  • Donated medicines and medical supplies cannot be used in or marketed in or returned to North America, or sold or exchanged for property or services;
  • Donated medicines and medical supplies must respond to the specific health needs of the country of final destination and be dispensed as agreed upon with HPIC to an identified group of beneficiaries and within a specified project;
  • Only licensed healthcare practitioners may dispense the medicines. Recipient hospitals and/or clinics and physicians must be aware of any imminent donation. In case of recall, recipients must adhere to HPIC's recall policies and procedures;
  • Medicine and medical supplies must be dispensed by trained healthcare practitioners who are able to read Canadian (English / French) packaging and instructions;
  • Donated medicines and medical supplies will be distributed free of charge and without discrimination as to race, religion, age, or gender;
  • HPIC must be promptly advised of any change of destination and/or distribution plan. Any change in the date of departure should be promptly communicated with HPIC for further instruction;
  • HPIC will be notified immediately of any loss, diversion or misuse of the donated medicines;
  • HPIC will be notified immediately of any adverse reaction from use of medicine(s);
  • The destination country's procedure to clear the donated medicines through customs will be respected. HPIC is not responsible for foreign customs charges or taxes;
  • Medicines and medical supplies will not be used to support terrorist activities or organizations linked to terrorism;
  • In accordance with World Health Organization Guidelines for Drug Donations, all donated medicines must be distributed and used before their expiry date, and any expired medicines must be destroyed in an environmentally safe manner;
  • All medicines and medical supplies must be used in adherence to HPIC's Gender Equity Policy and HPIC's Environmental Policy (please inquire with HPIC for copies of these policies);
  • The Code of Conduct for the International Red Cross and Red Crescent Movement and NGOs in Disaster Relief and The Inter-Agency Standing Committee Plan of Action on Protection Against Sexual Exploitation must be adhered to in the delivery of humanitarian aid in emergency situations;
  • The "Confirmation of Safe Arrival" form included with shipping documents must be completed upon arrival of medicines at the final destination and returned immediately to HPIC;
  • The "Project Report" form included with the shipping documents must be completed and returned, along with photos, within 3-6 months after the arrival of the shipment in the country of destination.