Personal details

Full Name: 

Date of Birth:

Do you have a valid passport?

Passport Expiration:

Your current address:

Your current occupation:

Email:

Cell phone:

Home Phone:

Emergency Contact

Name:

Relationship:

Address: 

Email:

Cell phone:

Home/other phone:

Program Choice:

Although Sudan-Reach has designed a specific program schedule, we would still like to know what areas you would most like to contribute to. Please let us know any specific interest areas you might have:

Do you certify that you are available for travel during the month of January 2009? Yes      No

Have you previously participated in voluntary activities?

Yes    No, if yes please explain:

Have you ever traveled or lived abroad?

Yes       No

What languages do you speak?

References:

Please give the names and contact details of two references

Name:

Occupation:

Address:

Tel:

Name:

Occupation:

Address:

Tel:

Medical Information

Do you suffer from any allergies? 

Yes No If yes, please describe which kind and what the symptoms are:

Do you take medication for your allergies? 

Yes   No

Do you have any special dietary requirements? 

Yes   No    If yes, please specify:

Do you require any ongoing or temporary medical treatment? 

Yes   No      If yes, please specify:

Are you receiving treatment/counseling for any physical or psychiatric conditions?

Yes   No      If yes, please specify (have a condition may not exclude you from participation):

To the best of your knowledge have you been in contact with any contagious or infections diseases or suffered from anything in the last four weeks that may be contagious or infectious? 

Yes   No     If yes, please explain:

Have you had any recent injuries? 

Yes   No     If yes, please explain:

When did you last have a tetanus injection?

Year:      I can't remember

Are you currently on any medications?

Yes No

Please give details of any other relevant information regarding your health:

Please give the contact details of your family doctor:

Name:

Telephone:

Address:

Please check that you are have or are able to provide/obtain:

A Valid U.S. passport, Green Card, or permanent residency

A deposit of $1500 due on 11/3/2009

or

Payment of the entire balance of $3250: 

A signed document from your doctor's office stating your ability to participate in this volunteer opportunity. 

Vaccinations against Malaria, Tetanus, and Meningitis. I will provide proof of vaccinations from my doctor's office. 

Other recommended vaccinations include Yellow fever, Cholera, and Typhoid.    

Do you have health insurance? 

Yes     No

Terms and Conditions.  PLEASE READ CAREFULLY

• Participants agree to communicate with the Program Director in the event of any difficulty or problems arising

• Participants agree to travel as a group and remain with the group for the entire length of their stay

• Participants will travel to Sudan out of Washington DC. You are responsible for booking and purchase of flights to Washington DC (if applicable) and will arrive on the morning of [Sun Jan 4th 2009] for training. The group will depart to Sudan from Washington, DC. (Exceptions might apply if you live in NY, or Boston. Contact us if this applies to you.)

• No application can be processed without the deposit of $1500 or full payment of $3250.

• Participants traveling to Sudan agree to seek medical advice or medical/dietary issues prior to departure. In addition, Participants agree to provide proof of vaccinations for the conditions listed on the "Checklist of Documents Needed" section. Failure to provide this documentation will disqualify you from the trip. 

• Applicants should be as flexible as possible in their requirements regarding housing and living arrangements. Sudan-Reach will make every effort possible to provide comfortable, clean, and appropriate lodging. 

• All prices are quoted in U.S. dollars. The remaining balance of the program fee should be paid no later than Dec 15th, 2009 

• Sudan-Reach reserves the right to cancel any participant for whom full payment has not been received by Dec 15th, 2009. In the event of cancellation, the cancellation policy (below) shall apply.

• Sudan-Reach accepts no liability whatsoever for any loss, illness or accident suffered by a participant during the program howsoever caused. 

The following scale of cancellation charges shall apply: 

• Cancellations received greater than 60 days  before departure will entitle the participant to a refund of program payment less $250 administrative fee. 

• Cancellations received between 60-45 days before departure entitle participant to 50% program payment. 

• No refund will be issued to participant canceling 44 (or less) days prior to scheduled departure date. 

• No refund will be issued to a participant canceling once a project has started. 

• In the event that Sudan-Reach should cancel a project, Sudan-Reach will provide a total refund to the participant. 

Sudan-Reach reserves the right to expel anyone who is a danger to him/herself or others or who exhibits misconduct or who, in the opinion of Sudan-Reach or its agents, is unable for any reason to safely or satisfactorily complete the program. In the event the participant is expelled by  Sudan-Reach, no refund will be given to the participant and the participant shall surrender the participant's work permit to Sudan-Reach and exit the country of Sudan within twenty-four hours following delivery of the notice of expulsion. 

RISKS

The participant, by signing this application and initialing next to those provisions affirms the following statements and agreements:

Please initial the boxes  below:

I agree to travel and participate at my own risk

I acknowledge that the risks of traveling to and living in Sudan and I agree to travel and participate at my own risk and agree to assume full responsibility for myself and my property.

I understand that Sudan-Reach and its agents, both domestic and international, assume no liability for any personal harm or illness to myself or for any loss or damage to any personal property that I may bring to or purchase in Sudan.

I, my heirs, and my personal representatives and assigns, hereby absolve Sudan-Reach and its agents and hold them harmless from any claim or demand that I, my heirs, and my personal representatives and assigns might conceivably assert for any such harm, illness, loss or damage. It is my intent to be legally bound by this statement. 

I understand that I am not required to participate in any activity in which I do not feel comfortable, but my decision not to participate does not entitle me to a refund for any portion of the project fees. 

I have or will assess my own personal needs by consulting with a physician concerning immunizations, medical and dietary needs prior to my project participation.

I agree to follow all applicable rules, policies and guidelines of Sudan-Reach whether made part of this application or not and whether published or not. I further agree to follow all applicable rules, policies guidelines and laws of the country and communities of Sudan and the United States of America. 

Travel Delays:

The possibility exists for transport delays or cancellations due to weather conditions, industrial disputes or other causes; whilst Sudan-Reach greatly regrets any inconvenience caused to participants, it can not be held responsible for any repercussions, financial or otherwise caused by weather conditions, fire, flood, strike, industrial dispute, hostilities, political unrest, riot, civil commotion, inevitable accident, act of God, or other circumstance amounting to force majeure. 

Travel insurance:

Sudan-Reach does not require that you purchase either trip cancellation insurance or medical/emergency evacuation insurance, however, Sudan-Reach is not responsible for loss or damage to the participant or the participant's property for failure to do so. 

Declaration:

Have you ever been convicted of a Criminal Offence? Yes No

I confirm that nothing within my personal or professional background deems me unsuitable for a post which involves working with children or minors under the age of 18. 

I declare that I have completed each section above to the best of my knowledge and that I have read and accept the terms and conditions of this program.

I understand that by signing and submitting this application that I am agreeing to the requirements of Sudan-Reach. I have read this agreement in its entirety and agree to its terms.

After submitting this application, you will be asked to make payment. Please let us know how much you will be paying:

$3250.00 (Entire balance) $1500 Deposit

If you choose to pay a deposit, please note that it will be due on or before [date to be determined] in order to reserve a spot. In that event your remaining balance will be due on or before 11/3/2009. However, if you do not pay the deposit by 11/3/2009, you will be required to either pay the entire balance immediately or be disqualified from the trip. 

By typing our name below, you agree that this is valid as your signature and you have read and agree to the terms, rules, and guidelines stated above.

Your electronic signature

Type your full name:

Date of Application: