BCS Trip Application

iam1ru Trip Application for BCS Students

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 bring it to your BCS trip contact.

Registration deadline:

General Info

Date *

Trip Location- El Salvador, March 2012

Name (as it appears on your Passport) *

Name that you prefer to be called *

Address *

City *

Province/State *

Postal Code/Zip Code *

Home Phone Number *

Work/Cell Phone Number *

Email *

Fax *

T-shirt for adult or youth? *

Adult Child/Youth

T-shirt Size *

Birthdate (day/month/year) *

Are you a citizen of Canada? *

Yes No

If No, country of Citizenship? *

Emergency Contact

Name *

Phone Number *

Work/Cell Phone Number *

Relationship to you? *

Passport Photocopy

Choose one *

I am attaching a photocopy of my passport to this application (see right) I will bring a copy to my BCS trip contact

Upload File (Passport photocopy) *

Max file size: 20MB

Online Profile - for pledges/fundraising

Please create an online profile for me to collect pledges toward my trip *

Yes No

If you said "yes" to online profile, what information would you like us to post? (why you want to go, any other relevant info) *

Upload photo for online profile *

Max file size: 20MB

PART B (Background Info)

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

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

Previous Trips

Have you served on any previous humanitarian aid trips? *

Yes No

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

Skills & Training

PI’s Volunteer Trips require flexibility and adaptability. We ask that participants be willing & prepared to lend a hand in any number of tasks/activities.

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

History

Have you ever been arrested? *

Yes No

If yes, were you convicted? *

Yes No

If yes to either question, please explain *

Health

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, high altitudes, extreme temperatures etc? *

Yes No

If yes, please explain *

References

To assist PI 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 *

Address *

Phone Number *

Occupation *

How do you know them? *

Name *

Address *

Phone Number *

Occupation *

How do you know them? *

Name *

Address *

Phone Number *

Occupation *

How do you know them? *

PART C - (Parental Consent)

Name of mother (or legal guardian) *

Home Phone Number *

Address *

Work/Cell Phone Number *

Name of father (or legal guardian) *

Home Phone Number *

Address *

Work/Cell Phone Number *

PART D (Photo & Video Release)

Photo/Video Release

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

Personal Liability & Covenant Form

Please download the pdf form below, and return the signed form to Mrs. Farrow (or other BCS trip contact)

pl__c_form_-_generic_.pdf
File Size:	65 kb
File Type:	pdf

Download File

Thank you for your application. Please click SUBMIT below to forward it to the PI office.

Submit