Climb UP So Kids Can Grow UP

Transcription

1 NEPAL EVENT TRIP APPLICATION EVENT TRIP PREFERENCE: Country/Countries of Interest Nepal Trip Dates PERSONAL INFORMATION: First Name Middle Name Last Name Mailing address City State / Province Zip / Postal Code Country - Home Phone Cell Phone address ( is the preferred method of communication) Date of Birth (mm/dd/yy) Gender: Male Female Occupation If student, school name Traveling with a companion or group? Yes No (Each person must fill out their own application) Group name Companion name Companion relationship PASSPORT INFORMATION: Passport Number Expiration Date (mm/dd/yy) Country of Issue ADDITIONAL INFORMATION: Why are you interested in participating in this event? Previous international travel experience (please describe, including where and when):

2 Application Page 2 Previous volunteer trip experience (please list countries and length of stay): Please list any special skills (first aid, photography, writing, construction, etc): LANGUAGES (Other than English): Fluent Conversational Beginner HEALTH: Physical fitness: excellent good fair poor Medical conditions / allergies / physical limitations: Special Dietary requirements: Please send your completed application to us at: Mail: info@afcaids.org Climb Up Event Trip c/o AFCA 6221 Blue Grass Avenue Harrisburg, PA Or Fax: (717)

3 Event Trip Participant Acknowledgement Special Terms and Conditions for International Trips IMPORTANT: Please be sure that you read and understand the terms and conditions set forth below before signing this acknowledgement form. AFCA and its host community and / or logistics partners take many precautions to ensure the security and safety of all AFCA trip participants. However, when travelling internationally, especially to and in developing countries, unforeseen situations may arise. Security, health or safety may be compromised due to political instability, acts of violence or terrorism, extreme inclement weather, risks to health, and other circumstances. If circumstances arise before or during your trip that compromise safety, health or security, your trip may need to be cancelled or terminated prior to the anticipated end date. Accordingly, AFCA reserves the right to cancel or terminate early any trip at any time, at its reasonable discretion. AFCA will not be held responsible for any costs incurred by a participant as a result of cancellation or early termination of any trip. All participants should consider purchasing their own Trip Cancellation Insurance. In preparation for the trip, it is imperative for participants to read all Team Leader communications carefully and thoroughly and to ask any questions that are not addressed. Due to the nature of AFCA s international event and / or volunteer trips, participants need to have a high degree of flexibility and patience and be able to adapt to changes and challenges that will undoubtedly arise. AFCA expects all participants to respect their fellow participants and the residents of the communities in which they are staying. AFCA reserves the right to ask any participant to leave the group if the participant engages in acts of serious misconduct, including violations of AFCA policies, violations of the law (of the host country or sending country if you are traveling internationally), and acts that are determined by AFCA or your team leader to constitute serious misconduct. If you are asked to leave the group due to an act of serious misconduct, you shall do so at your own expense. I,, acknowledge that I have read, understand, and agree to the terms and conditions set forth above. Signature: Date: Address: Phone (H): Phone (W): American Foundation for Children with AIDS 6221 Blue Grass Avenue, Harrisburg, PA Page 1

4 Release and Waiver of Liability PLEASE READ CAREFULLY! THIS IS A LEGAL DOCUMENT! IMPORTANT: Each participant must sign this Release and Waiver of Liability before being allowed to participate on an American Foundation for Children with AIDS trip. Please fill this out completely with the required information in all blanks provided. Please be sure that you read and understand the terms and conditions set forth below before signing this acknowledgement form. This Release and Waiver of Liability (the Release ) is executed by (the Participant ) on the date indicated with the Participant s signature below, and in effect for one full calendar year from this date, in favor of AMERICAN FOUNDATION FOR CHILDREN WITH AIDS, a nonprofit corporation organized and existing under the laws of the State of Pennsylvania, USA, its affiliated organizations in other nations, its directors, officers, employees, advisors, team leaders, and agents (collectively, AFCA ). I, the Participant, desire to participate on an AFCA trip team and engage in the activities related to being a Participant on that team. I understand that the activities may include but are not limited to: traveling to and from other countries, traveling to and from other cities and towns, consuming food prepared locally and living in basic accommodations. There may also be strenuous physical activities and period of times at high altitude. For any trip with a volunteer component, activities may also include constructing and rehabilitating residential, community, medical and / or school buildings, volunteering at a medical facility, orphanage and / or school. I hereby freely and voluntarily, without duress, execute this Release under the following terms: 1. Waiver and Release. I, the Participant, release and forever discharge and hold harmless AFCA and its successors and assigns from any and all liability, claims, and demands of whatever kind or nature, either in law or in equity, which arise or may hereafter arise from my participation on a Participant team with AFCA. I understand and acknowledge that this Release discharges AFCA from any liability or claim that I, the Participant, may have against AFCA with respect to any bodily injury, personal injury, illness, death, or property damage that may result from my participation with an AFCA Team, whether caused by the negligence of AFCA or its directors, officers, employees, or agents or otherwise. I also understand that AFCA does not assume any responsibility for or obligation to provide financial assistance or other assistance, including but not limited to medical, health, disability or emergency evacuation insurance, in the event of injury, illness, death or property damage (see insurance requirements below). 2. Insurance. I, the Participant, understand that AFCA does not carry or maintain health, medical, disability or emergency evacuation insurance coverage for any Participant. I acknowledge that I am responsible for procuring health, medical, disability insurance and emergency evacuation insurance for myself and will provide proof of insurance on request. AFCA makes no representations as to whether your own personal health insurance policy would cover any expenses incurred while on this trip. The Participant should determine this for yourself before leaving on the trip and carry appropriate insurance information with you. 3. Medical Treatment. I hereby release and forever discharge AFCA from any claim whatsoever which arises or may hereafter arise on account of any first-aid, medical treatment, or other services rendered in connection with my work with AFCA. American Foundation for Children with AIDS 6221 Blue Grass Avenue, Harrisburg, PA Page 1

5 4. Assumption of the Risk. I recognize and understand that my time with AFCA may include activities that are inherently hazardous, including, but not limited to, hiking and / or climbing on difficult trails, often in remote areas, and spending time at high altitude. A trip with a volunteer component may include construction activities, loading and unloading of heavy equipment and materials, and local travel to and from the work sites. I also understand that there is some inherent risk in consuming local foods and living in local accommodations available in the country(ies) visited. I further understand that I may be traveling to and from locations where there is a risk of terrorism, war, insurrection, criminal activity, inclement weather, or other circumstance that could threaten my safety or health. 5. Hostages. I understand that, it is AFCA s policy that it will not pay ransom or make any other payments in order to secure the release of hostages. 6. Photographic Release. I grant and convey unto AFCA all right, title, and interest in any and all photographic images and video or audio recordings made by AFCA during my work for AFCA, including, but not limited to, any royalties, proceeds, or other benefits derived from such photographs or recordings. 7. Other. I expressly agree that this Release is intended to be as broad and inclusive as permitted by the laws of the State of Pennsylvania in the United States of America, and that this Release shall be governed by and interpreted in accordance with the laws of the State of Pennsylvania. I agree that in the event that any clause or provision of this Release shall be held to be invalid by any court of competent jurisdiction, the invalidity of such clause or provision shall not otherwise affect the remaining provisions of this Release which shall continue to be enforceable. I hereby expressly and specifically assume the risk of injury or harm in these activities and release AFCA from all liability for injury, illness, death, or property damage resulting from the activities of my time with AFCA. To express my understanding of this release, I sign here with a witness. Participant: Name: Signature: Address: Phone (H): Phone (W): Date: Witness: Name: Signature: Address: Phone (H): Phone (W): Date: American Foundation for Children with AIDS 6221 Blue Grass Avenue, Harrisburg, PA Page 2

6 Emergency Contact Information Name: Event Trip Dates: Country: In case of emergency, please contact: Name Relationship: Address City State / Province Zip/Postal Code Country Day phone Night phone Personal physician information: Name Day phone Night phone Medications being taken (name and dosage) Personal health insurance information: NOTE: You are responsible for procuring your own travel medical insurance, including emergency evacuation insurance. Please be sure to read your travel insurance benefits and coverage information to ensure that you have medical coverage for the country you are visiting. Company Policy number Insurance agent Agent phone Coverage includes emergency evacuation? yes / no Please return this completed form, Release of Waiver and Liability and a copy of the ID page of your passport to us at: Mail: info@afcaids.org Climb Up Event Trip c/o AFCA 6221 Blue Grass Avenue Harrisburg, PA Or Fax: (717)