iam1ruforms

iam1ru Trip Application

This online application is divided into various sections. Please read instructions carefully to make sure you are providing all the necessary information. Thank you!
PART A - General information - to be completed by all applicants
PART B - to be completed ONLY by applicants who have NOT been on a PI trip previously
PART C - to be completed ONLY by applicants under 18 years of age
PART D - Photo/video waiver - to be completed by all applicants
PART E - Personal Covenant & Liability Form - to be completed by all applicants
PART F - Travel Insurance Questionnaire - to be completed by all applicants

NOTE: you will be asked to attach a photocopy of the photo page of your Passport. You may either scan it, take a good quality digital photo or mail it to the PI office.

Part A (to be completed by all applicants)

Name (as it appears on your passport) *

Name that you prefer to be called *

Street Address *

Province/State *

Phone Number *

Email *

Are you a citizen of Canada? *

Yes No

City *

Postal Code/Zip Code *

Work or Cell Phone Number *

Birthdate *

If no, country of Citizenship? *

T-shirt for Adult or Youth *

Adult Child/Youth

T-shirt size *

T-shirt style *

Unisex - regular cut Women's regular cut (just a bit shorter) Women's fitted v-neck (fits normal, not tight, but is tapered a bit) )

Emergency Contact

Name *

Relationship to you? *

Phone Number *

Work or Cell Phone Number *

Food Allergies/Issues

Do you have any food allergies or concerns we should know about? *

YES NO

If you answered YES to food concerns, please describe *

Health

What is your current condition of health? *

Traveling in another country may mean limited health resources and require greater physical stamina.

Considering this, do you have any health needs, conditions or physical limitations? *

YES NO

If YES, please explain: *

Is there any reason you would not be able to engage in rigorous outdoor activity, primitive living conditions, high altitudes, extreme temperatures etc? *

YES NO

If YES, please explain: *

Are you taking any medications on a regular basis? *

YES NO

If YES, please explain *

Do you have any allergies? *

YES NO

If YES, please explain *

Passport Photocopy

Choose One *

I am attaching a photocopy of my passport (see right) I will mail a copy to the PI office

Upload File (Passport Photocopy) *

Max file size: 20MB

Online Profile - for pledges/fundraising

For each team trip, we create a webpage with a pic and brief "blurb" about each member of the team. This provides a simple way for team members to fundraise - by giving the link to family, friends and co-workers. If you do not upload a photo, we will post a generic cartoon/silhouette picture beside your name.

What information would you like us to post? (why do you want to go, any other relevant info) Note: if you leave blank, we will enter a general statement on your behalf. *

Upload Photo for Online Profile *

Max file size: 20MB

PART B (to be completed only by applicants who have NOT previously been on a PI trip)

How did you hear about PI and/or this trip? *

Have you served on any humanitarian trips prevously? *

Yes No

What is your interest in this trip? (why do you want to go?) *

If yes, briefly describe location, date and the organization that facilitated the trip. *

Family

If married, name of spouse? *

Does your spouse support you going on this trip? *

Yes No

Skills and Training

PI's volunteer trips require flexibility and adaptability. We ask that participants be prepared to lend a hand in any number of tasks/activities.

With this in mind, describe any skills, training or experience that may come in handy on a trip: *

History

Have you ever been arrested? *

YES NO

If you answered YES to either question, please explain: *

If yes, were you convicted? *

YES NO

References

To assist us in evaluating your application, we need references from people who know you well. Please provide us with names of appropriate individuals. Do not list relatives.

Name *

Occupation *

Phone Number *

How do you know them? *

Name *

Occupation *

Phone Number *

How do you know them? *

Name *

Occupation *

Phone Number *

How do you know them? *

PART C (complete this section if under 18 years of age)

Name of mother (or legal guardian) *

Home Phone Number *

Name of Father (or legal Guardian) *

Home Phone Number *

Address *

Work or Cell Phone Number *

Address *

Work or Cell Phone Number *

PART D (to be completed by ALL applicants)

Photo/Video Release Form

I hereby give permission for images of myself and/or my child, captured during PI activities through video, photo and digital camera to be used on the PI/iam1ru website, blog or print materials solely for the purposes of furthering the mission of Possibilities International, and waive any rights of compensation or ownership thereto.

Agreeing to the above conditions in the photo/video release form and registering online for this trip on behalf of myself or as legal guardian of a trip applicant in an electronic format authorizes you to accept this Photo/Video release form as signed by me.

I have read the Photo/Video Release and agree to the conditions *

YES NO

Parent/guardian's name (if applicant is under 18 years of age) *

PART E (to be completed by ALL applicants)

Possibilities International
PERSONAL COVENANT AND LIABILITY RELEASE
The guidelines listed below are recommended for those participating in this journey. You go not as a tourist, but as a guest of another country. The countries we volunteer in do not have the same conveniences you are used to at home. It is very important to be flexible and willing to adjust to the expectations of your host and PI leaders.

I recognize and accept the following conditions which will further the usefulness and safety of our short-term trip. If accepted as a member of this PI team, I agree to:

Release and discharge the organizations and individuals which helped make these arrangements, including Possibilities International, their agents, employees, officers, and volunteers, from all claims, demands, actions, judgments, or executions that I have ever had, or now have, or may have, or which my heirs, executors, administrators, or assigns may have or claim to have, against these organizations, their agents, employees, officers, and volunteers, and their successors or assigns, for all personal injuries, known or unknown, and injuries to property, real or personal, caused by, or arising out of this journey. I intend to be legally bound by this statement.
Adopt an attitude that I am on this team to try to understand the host culture, not to convince them of my own viewpoint or style. I go knowing that there are many different ways to accomplish the same objective and know that my way may not necessarily be the best.
Abstain from making derogatory comments or arguments regarding people, politics, sports, religion, race, or traditions.
Go as a servant and to adopt that attitude when dealing with my fellow team members and the people I meet during the trip.
Accept and submit to the leadership role and authority of the trip director/trip leaders and promise to abide by their decisions as they concern this trip.
Acknowledge that by engaging in this journey, I am subjecting myself to certain risks voluntarily, in addition to those risks that I normally face in my personal and business life, including but not limited to such things as health hazards due to poor food and water, diseases, pests, and poor sanitation; potential danger from lack of control over local population; potential injury while working; and inadequate medical facilities.
Understand that our team’s work is but a tiny speck on the bigger picture that our partners are trying to accomplish. I promise not to be overly demanding, to do my best not to offend or cause embarrassment for the local host and to help them attain their long-term goals.
Attend all team meetings possible, both prior to departure (if any are scheduled) and during the trip itself.
Expeditiously follow up on all requirements for passports, visas, financial obligations, vaccinations, travel insurance, etc.
Refrain from meddling, complaining, and obscene or insensitive humor. I understand that I must travel with the rest of the team, unless other prior arrangements are made.
If a loved one or dear friend is traveling with me, we agree to interact with all members of the team, not just one another. I promise not to seek or engage in new romantic relationships with team members during the trip.
Avoid any actions that might be perceived as amorous attentions toward any people I meet while on the trip.
Abstain from using tobacco or alcoholic beverages while in the host country. Abstain from any illegal drugs or prohibited activity while on this trip.
Remember we are the unknown guests from another part of the world and will be watched very closely. I will not take the important responsibility of setting an example lightly.
Refrain from giving gifts, such as money, clothes, jewelry, tape players, etc. to the locals. Although the intent of the giver is good, the result after we leave causes problems for our host, and jealously and bitterness among those locals who received no such gifts. If I feel compelled to give a gift to someone I have met, I will consult first with the trip director(s) before I promise or give the gift, and I promise to let him or her make the final decision on this matter.
Act as a representative of Possibilities International - I will respect the advice I am given concerning attire, eating and drinking, and other such traditions that will help me to assimilate into the local community.
Understand that every member of this group is expected to share freely from their particular blessing and talents, whether that is a skill such as music, art, carpentry, or basic hard work. I agree to participate in these ways as fully possible.
I agree that in the event my conduct is considered so unsatisfactory that it jeopardizes the success of the trip, and that mediation during the trip has failed to correct my behavior, that my services in connection with this trip shall end and I shall return home immediately at my own expense.

I ATTEST AND VERIFY THAT I AM 18 YEARS OF AGE OR THAT I AM SIGNING AS THE LEGAL GUARDIAN ON BEHALF OF A TRIP APPLICANT UNDER THE AGE OF 18 YEARS.

Agreeing to the above conditions in the Liability Form and registering online for this trip on behalf of myself or as legal guardian of a trip applicant, in an electronic format authorizes you to accept this Personal Covenant & Liability Form as signed by me.

I have read the Personal Liability and Covenant form and agree to the conditions *

YES NO

TRAVEL INSURANCE CRITERIA

Our travel insurance company requires that you read the following information and answer YES or NO to the questions that follow each section.

1. Coverage is NOT AVAILABLE to any individual who:

a) has been diagnosed with a terminal illness;
b) has been diagnosed with or has had an episode of congestive heart failure;
c) has Acquired Immune Deficiency Syndrome (AIDS) or Human Immunodeficiency Virus (HIV);
d) has Alzheimer’s disease or any other type of dementia;
e) has received any type of treatment for pancreatic cancer, liver cancer or any type of cancer that has metastasized;
f) has been prescribed or used home oxygen treatment in the last 12 months;
g) has had a major organ transplant (heart, kidney, liver, lung); or
h) has received kidney dialysis treatment in the last 12 months.

Do any of the above statements apply to you? *

YES NO

2. To be eligible for coverage you must:

a) be at least 15 days old; and
b) be insured for benefits under a Canadian government health insurance plan during the entire period of coverage; and
c) be currently in good health and know of no reason to seek medical consultation during the period of coverage; and
d) not reside in a nursing home and receive nursing care; and
e) not reside in a convalescent home or rehabilitation centre; and
f) not require assistance with activities of daily living.

Are there any of these criterion you do NOT meet? *

YES NO

If YES to either question above, please provide additional information: *

Thank you for your application. When you click SUBMIT below, you will be redirected to the iam1ru home page.

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