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Registered charity number: 1105455        Company number: 5044723

Project registration form

NB The issue of this form by International Health Partners (UK) Ltd does not amount to a contract or any offer to enter into a contract.  IHP will consider all applications carefully but cannot guarantee to issue donated product to all applicants and reserves the right to decline applications from any Organisation or for any particular project without giving any reason.

Your attention is drawn to the “Important Notice” at the end of this form.  By completing and sending this form to IHP you confirm your Organisation’s acceptance of the terms set out in that Notice.

1. UK Organisation(s) making request:

Organisation(s):  

                

 

Registered charity no (if applicable):

  

Address:

 

 

  

Contact details:

  

Telephone:

  

Fax:

  

Email:

  

2. Name of Project: …………………………………………………………………

3. Who will be the contact within your organisation for IHP?

Name:

 

Position:

  

Address:

 

 

  

Telephone:

  

Fax:

  

Email:

  

4. Please describe the project: (use additional sheets if required)

  • Full description of the project:
  • Objectives of project:
  • Expected start date and duration:
  • Location (address):
  • Partners involved with the project:
  • Linkages into existing local health care development strategies:
  • Steps taken to ensure sustainability:
  • Name of local implementation organisation (if different from requesting organisation) and description of structure, official status and role in the project:

5. Please list the medicines and medical supplies you would like to request from IHP.

Names of medicines and medical supplies requested                    Quantity

   
   
   
   
   
   
   
   
   
   

(Please use additional sheet if more room is required)

6. Are you aware of and do you endorse the World Health Organisation (WHO) Guidelines for Drug Donations?

7. How will supplies be transported from IHP's’ warehouse to final destination?

8. Who will provide IHP with a narrative report or follow-up on the project? (Pictures are encouraged as a supplement to a narrative report.)

9. Secondary contact who is familiar with the project and may be contacted by IHP?

Name:

  

Position:

  

Address:

 

 

  

Telephone:

  

Fax:

  

Email:

  

Declaration:

We hereby declare that any donated medicines, vaccines and medical supplies which may be provided by International Health Partners (UK) Ltd pursuant to this project registration, will be used to provide treatment free of charge, to the sick and suffering overseas without discrimination as to race, religion, age or gender; that such supplies will not be sold or exchanged for products or services and will not be used to support any terrorist activity anywhere in the world, nor used for any illegal purpose or any purpose other than the project identified herein; that prescription medicines will be handled in a secure and appropriate manner, prescribed only by licensed health care practitioners and that all medicines, vaccines and medical supplies will be used before expiry or destroyed in an environmentally secure manner, as indicated by the manufacturer on the package. 

Within 30 days of the arrival of the medicines, vaccines and medical supplies at the location of the project described herein, I will ensure that International Health Partners (UK) Ltd is supplied with a confirmation of safe arrival of shipment as outlined in the document Confirmation of safe arrival.

Within 30 days of arrival back in the UK or completion of the Project, I will ensure that International Health Partners (UK) Ltd is supplied with a project report, in the format outlined in the document Project report form.

We also understand that failure to comply with International Health Partners (UK) Ltd's reporting requirements could affect future shipments of medicines to this or other projects.  I understand that International Health Partners(UK) Ltd reserves the right to do a field audit to confirm the integrity of this donation.

We also confirm that we have read and accept the terms of the “Important Notice” at the end of this form.

The above information is to the best of our knowledge, true and accurate.

Sponsoring organisation:

Signature:

Printed name:

Date:

(This Project registration form may be filled out electronically, but a signed copy of the original must be faxed in its entirety to IHP at the address below.)

International Health Partners
The Fold
Beech Hill
Wadhurst
East Sussex
TN5 6JR

Fax:  01892 784 696

Attn: Ruth Dunnett

IMPORTANT NOTICE

International Health Partners (UK) Limited is a charity and relies for its work on donations of surplus pharmaceutical products by reputable manufacturers and distributors.  Accordingly:

  • Any acceptance by IHP of a request for donated product will not amount to a contract or any other legally enforceable obligation between IHP and the Organisation (“the Organisation”) requesting such product.
  • IHP will in good faith use reasonable endeavours to provide agreed donated product to the Organisation according to agreed timescales, but IHP accepts no responsibility for late or failed delivery.
  • IHP obtains donated product in good faith from reputable sources but accepts no legal responsibility of any kind for such product or its use.  This includes (but without limitation) the quality, effectiveness, date of time expiry, appropriateness for use and/or method of use of donated product or for any damage or loss that may arise in storage or transit or for any personal injury that may arise out of use or misuse of donated product.  The Organisation accepts and agrees that it is the Organisation’s responsibility to ensure that donated product is not out of date or damaged and for the suitability and method of its use in accordance with sound medical practice.
  • The Organisation waives all claims it may have against IHP in respect of any of the above-mentioned matters.