C.U.R.E. Clinics Participant Application 1International Travel Experience & Expectations2Personal Information3Agreement *Thank you for applying to participate in a Project C.U.R.E. Clinics and College trip. BEFORE STARTING THIS APPLICATION please have your current passport available. As you will not be allowed to start and stop/save this application once you have begun. Your information will not be saved until you submit the fully completed application. This application should only take about 10-15 minutes to complete.*To successfully submit this form, all fields must be filled out. Please use N/A if the field is not applicable.Select Trip*Cote d’Ivoire - May 25-June 6, 2023Paraguay - May 25-June 5, 2023India - July 5-17, 2023India - November 1-13, 2023Volunteer Type* Medical Non-Medical Professional Skill Set (Please include licenses and certifications)* Are you a returning Project C.U.R.E. international travel participant?* Yes No Please tell us about your international travel experience, if applicable.*Please list countries and purpose of travel.Please indicate language skills and proficiency level:*Each volunteer is expected to function as a team member and adapt to unexpected circumstances. For example: last minute logistic changes, no hot water, no air conditioning, limited electricity, bucket bathing. Are you willing/able to adapt to these types of changes?* Yes No Are you currently taking any medications?* Yes No If you answered “Yes”, please list medications here* Are you currently under a doctors care? If so, please explain* Please list any current medical and/or physical conditions/limitations (ex. High BP, Diabetes)* Do you require any physical accommodations? If so, please explain* Do you have any dietary restrictions? If so, please indicate here* Name Exactly as it appears on Passport* First Middle Last Phone*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAndorraAngolaAnguillaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire - Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandColombiaComorosCook IslandsCosta RicaCôte d’IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDemocratic Republic of the CongoDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFijiFinlandFranceFrench GuianaFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHoly SeeHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorth KoreaNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian TerritoriesPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRepublic of the CongoRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSão Tomé and PríncipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSomalilandSouth AfricaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands - BritishVirgin Islands - U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Email* Date of Birth* MM slash DD slash YYYY Biological Sex*MaleFemalePassport Number*Passport Date of Expiration* MM slash DD slash YYYY Nationality* Place of Birth* State of Residence* Emergency Contact Name* First Last Relationship* Emergency contact Telephone number*Emergency contact email* Emergency contract address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAndorraAngolaAnguillaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire - Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandColombiaComorosCook IslandsCosta RicaCôte d’IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDemocratic Republic of the CongoDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFijiFinlandFranceFrench GuianaFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHoly SeeHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorth KoreaNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian TerritoriesPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRepublic of the CongoRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSão Tomé and PríncipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSomalilandSouth AfricaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands - BritishVirgin Islands - U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Which Airport will you be departing from?* Shirt Size*XSSMLXLXXLScrubs Size*Women's XSWomen's SWomen's MWomen's LWomen's XLMen's SMen's MMen's LMen's XLMen's XXLUnisex XSUnisex SUnisex MUnisex LUnisex XLHow did you learn about C.U.R.E Clinics?* Agreement* I CERTIFY that all statements and information furnished in this Application are true, complete and correct to the best of my knowledge and belief and are made in good faith. I understand that any information furnished on this Application is subject to verification, and I agree to furnish supporting documents or information upon request and/or names, addresses and phone numbers (if known) of officials or other individuals who can substantiate the qualifications described above. I also understand that intentional misstatements or falsification will result in disqualification. International Flight Arrival Agreement* When booking international flights with Project C.U.R.E designated travel agent I understand that my flight must arrive at or before the indicated time on the "Suggested Flight Itinerary" document. I agree to meet the trip leader at the baggage claim of the final destination, unless I am otherwise notified. If my flights are delayed for any reason, I will notify the Trip Leader and Project C.U.R.E. Travel Department as soon as possible. If I fail to arrive in-country at the required time, I will be responsible for any additional transportation and/or accommodation costs my late arrival causes. Financial Agreement* I understand that my participant program fees are a non-refundable donation to Project C.U.R.E. Should I need to cancel my trip, I understand that I may use funds paid as a credit for future C.U.R.E. Clinics and must be used within 12 months of the cancelation date. Signature:* First Last Date* MM slash DD slash YYYY Thank you for your interest and for applying. Your application will be reviewed and we will contact you within the next two weeks.*The information provided in this application will not be shared outside of Project C.U.R.E. Your personal health information will only be used for purposes related to function and safety of Project C.U.R.E Clinic trips.
