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Trip Sign Up

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General Info

First Name

Last Name

Email

Phone

Mailing Address

Address

City

State

Zip Code

Country

Date of Birth

Sex

Male

Female

Trip Info

Trip Name

Passport Info

Name on Passport
Requires upload at end of form

Expire Date on Passport

Emergency Contact

Emergency Contact Name

Relationship to Traveler

Contact's Phone Number

Contact's Email

Health Info

Describe your health

Dietary Restrictions
None if not applicable

Allergies
None if not applicable

Medications
None if not applicable

Experience

Are you Licensed ? (Check all that apply)
Requires license/diploma upload at end of form

Dentist

Physician

Parametic/EMT

Dental Hygienist

RN/Nurse Practitioner

Ophthalmology

Dental Tech/Assi.

Other

Please Specify your specialty if available

How did you hear about Strong Villages?

Traveler Agreement

Traveler's Code of Agreement
In consideration of being accepted for participation in a Trip to I acknowledge that I am the Traveler(Name). I agree that I am legally permitted to travel, and will abide by all laws and regulations governing the countries, municipalities and international air travel jurisdictions to which the Trip is subject (Note *16 year old must have notarized document from both parents to travel without parents). Therefore, I, and or my guardian/parent if I am under 18 years old hereby agree to the following:

I have read and agree to all terms above.

Agreement of Participation
As a participant on this Trip, I will be representing my school/organization and Strong Villages Inc. (hereinafter SV) as well as my own country. I will conduct myself in strict accordance with my school/organization rules, the Student Rules of Conduct (applicable to students) the content of which I have read and understood. I will follow the laws of the countries I will visit and act as a goodwill ambassador. I recognize that each country has its own culture and I will demonstrate respect for these differences. I recognize that I will be exposed to new situations and experiences. I will take reasonable care of others and myself during the Trip and will not take any unreasonable risks that might endanger my, or another’s health or life. I will advise my teacher/ chaperone /leader and SV immediately if I am unable to attend, or continue to attend any part of the Trip. I have read and understand the AGREEMENT OF PARTICIPATION as stated above, and I will abide by its terms.

I have read and agree to all terms above.

Assumption of Risks
I understand that travel has inherent risks and I assume those risks voluntarily. I understand that I will be in unfamiliar surroundings and exposed to possible risks to my person and possessions. I understand that the aforementioned Trip involves use of facilities and services provided by third parties and which are out of the control of SV and my school/organization. I freely and voluntarily accept and assume all such risks, dangers and hazards and understand that SV, despite its most diligent efforts, may not be able to ensure my complete safety at all times. I have read and understand the ASSUMPTION OF RISKS as stated above, and I will abide by its terms.

I have read and agree to all terms above.

Assumption of Responsibility
I am medically fit and do not suffer any disabilities or physical limitations, other than those disclosed on the Trip application. I will take responsibility for obtaining any special vaccinations or preventative medications currently recommended or required by my physician. I will take only those medicines, drugs or cures that I am medically permitted to take in order to maintain my good health, and which have been lawfully prescribed for me. I will maintain due diligence of my medication and will not share them with others. My acceptance into the Trip may be revoked by SV and my school/organization at any time. I recognize that my repeated failure to exercise common sense and good judgment, refusal to accept directives of Trip leaders, or willful violation of explicit instructions delivered to me during the Trip may result in my expulsion from the Trip, and I may be sent home unaccompanied at my own expense. I acknowledge that the monies paid to SV are non-recoverable should I withdraw, be expelled or requested to leave the Trip. I have read and understand the ASSUMPTION OF RESPONSIBILITY as stated above, and I will abide by its terms.

I have read and agree to all terms above.

Liability Waiver
I release and hold harmless, Strong Villages Inc., its employees, students and agents from any and all liability for any loss, damage, injury or expense that I or my next of kin may suffer as a result of my participation in this Trip, including, but not limited to, accidents, acts of God, war, civil unrest, sickness, terrorism, transportation, scheduling, government restrictions or regulations, and any and all expenses I may incur while participating in the Trip. I understand this agreement cannot be modified except in writing by SV and that no oral modification or interpretation shall be valid. I have read and understand the LIABILITY WAIVER as stated above, and I acknowledge my responsibilities and the effect of this waiver.

I have read and agree to all terms above.

Photo Release Waiver
I understand that film and video crews and photographers may be present at times during the Trip. I agree to be photographed, filmed, videotapes or recorded and grant permission to use my image and likeness in any media for any lawful purpose in connection with Strong Villages or the Strong Villages Trip without compensation to me. I understand I may refuse to be interviewed or perform any action requested for purposes of photography and agree to remove myself from any event I choose, so that others may continue to be photograph or filmed on behalf of the Strong Villages programs.

I have read and agree to all terms above.

Waiver of Responsibility & Consent to Assume Risk
The traveler and or student traveler and family hereby acknowledge that said student has voluntarily decided to participate in one of the Strong Villages Inc. Trips (“the Trip”) as described above. I assume that the Trip may involve certain dangers and risks, inherent in the form of transportation, inclement weather, physical exercise and other recreational activities. Said student specifically assumes responsibility for his/her own safety, conduct, health condition, decisions and actions. In return for my remittance, I expect the teacher/chaperone to exercise reasonable care in arranging and conducting the Trip and I HOLD HARMLESS STRONG VILLAGES INC. for any claims or loss arising out of the Trip, or any act of a party rendering any of the services to the Trip, or the willful or negligent acts of any other Trip member, or other act or event, beyond the control of Strong Villages Inc. and/ or the teacher chaperone. Furthermore, in the event of a medical emergency, it is agreed that any necessary immediate care may be administered to the above-stated Trip participant as may be recommended by a certified health professional. I have carefully read this document and all relevant items and conditions outlined in the aforementioned materials that describe the Trip. I UNDERSTAND THAT IT IS A WAIVER OF LIABILITY AND ASSUMPTION OF RISK on my part in advance of my taking the Trip. I am aware that this is a contract between myself and Strong Villages Inc. and that it is only in reliance on this agreement that Strong Villages Inc. permits me / my student/child to go on the Trip.

I have read and agree to all terms above.

Release and Indemnification
I hereby release Strong Villages Inc., a 501(c) (3) non-profit entity, and all of its respective offices, directors, employees, agents, volunteers, contractors, heirs, successors and assigns (hereinafter the “Released Parties”), from prosecution or presentation of any claim for bodily injury, damages, wrongful death or for property loss or damage incurred in connection with my attendance and/or performance of health care services on the Strong Villages Trip or related activities. I understand that if I am volunteering in a dental and medical mission Trip for Strong Villages Inc., I am doing so at my own risk and that due to my occupational and/or other possible exposure to blood or other potentially infectious materials, I may be at risk of acquiring HIV, Hepatitis B or C virus or other blood borne pathogens. I hold the Released Parties harmless in the event that I test positive for any such diseases as a result of my activities at the Strong Villages dental and medical clinic. I understand that any independent traveling on weekends and holidays during the period covered by the Trip and For any extra activities (exam: zip lining, tubing, snorkeling, etc.) during or after the conclusion of the Trip will be at my expense and liability. I understand that Strong Villages Inc. is not responsible for me if I choose to travel independently before, during or after the Trip.

I have read and agree to all terms above.

Reservations, Payment Terms & Cancellation Policies
Trip registration and traveler’s applications are considered on a first-come, first-served basis. A deposit of $100.00 per traveler is necessary to secure enrollment in any SV Trip 60 days prior to departure. Failure to pay full balance by 30 days pre-departure may result in Participant Application denial and a nonrefundable fee of $100.00. If the Participant’s application is denied for non-payment or unsuitability of participation, the refundable portion of deposit funds will be returned to the Participant, minus any non-recoverable monies spent on the Participant’s behalf. Cancelation 30 days pre-departure is subject to a $100 cancellation nonrefundable fee. Note *Strong Villages does not provide airfare.

I have read and agree to all terms above.

Acknowledgment of Understanding
I have read the Traveler’s Code of Agreement, Waiver of Responsibility & Consent to Assume Risk with Medical Authorization, and the terms of registration, reservations and refunds, cancelation policies agreement. I fully understand their terms, and understand that I am giving up substantial rights, including my right to sue. I acknowledge that I am signing the agreement freely and voluntarily, on behalf of myself and/or minor child participant and intend by my signature to be a complete and unconditional release of all liability to the greatest extent allowed by law. I understand by agreeing, my signature is being transferred electronically, and I will not challenge the validity of the signature in any legal proceeding in which this document may be offered or used.

I have read and agree to all terms above.

Date

Electronic Signature-Traveler
(Your typed name is your legally binding signature)

Guardian/Parent Signature (if Traveler's under 18)

Passport Upload
All Travelers

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License Upload
Dental/Medical/Certification

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Diploma Upload
Dental/Medical/Certification

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