Trek Participant Form

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Page 1

Trek Participant Form
Please note that this application may take longer than 30 minutes to complete. Please use the feature in the top right-hand corner of this application to save your progress if you need to come back to complete your application.
Trek Participant Information










+123(45)678-910 | +123-045-67 89 10 | 01-234-56-78










Emergency Contacts

Should an emergency arise, or a change in schedule, buildOn will reach out to the following Emergency Contacts in the order they are listed.  Please make sure to keep buildOn updated if the numbers below change.  Be sure to include both daytime and evening phone numbers for your contacts, when possible.

 

buildOn will do our best to meet the language needs listed, however, this will not always be possible.  Please be sure to include at least one Contact who speaks and understands English so we can be sure of our ability to communicate when necessary.  

Emergency Contact #1





Please be sure to include at least one Contact who speaks and understands English so we can be sure of our ability to communicate when necessary.
Emergency Contact #2





Please be sure to include at least one Contact who speaks and understands English so we can be sure of our ability to communicate when necessary.
Emergency Contact #3





Please be sure to include at least one Contact who speaks and understands English so we can be sure of our ability to communicate when necessary.
Documentation for International Travel

I (or my child/ward) do not have a passport but recently applied:

To Whom It May Concern:

 

This letter is to give official notification that I or my child/ward will be traveling with buildOn on a buildOn Trek. I or my child/ward have applied for a passport and is waiting its processing.  I expect to have received the passport in time for me or child/ward to travel with buildOn.  


The standard processing time for a passport takes up to two months. If your application is not submitted at least 30 Days prior to your Trek For Knowledge Departure Date, you will need to have it expedited. The standard processing time for an expedited passport will take one to two weeks. 

I already have a valid U.S. Passport:
It is important to receive your passport details in order to register you with your Embassy in the country you are visiting, as well as ensure we have copies of these important documents in case they need to be replaced. 


(please be sure to enter exactly as viewed on passport)

(please be sure to enter exactly as viewed on passport)



I have a passport from another country (outside the U.S.)
It is important to receive your passport details in order to register you with your Embassy in the country you are visiting, as well as ensure we have copies of these important documents in case they need to be replaced. 


Check a box for each copy


(please be sure to enter exactly as viewed on passport)

(please be sure to enter exactly as viewed on passport)









I am traveling from outside the United States and I possess a non US passport.
Participant Medical History
Health Insurance

We provide MedEx International Evacuation and Medical Insurance to all Trek Participants. We require participants provide us with additional Medical Coverage Information for claims not covered by this insurance. (See MedEx MedEx International Evacuation and Medical Insurance in the Trek Guide).
Person Under Whose Name The Policy is Carried







Insurance Company Information




Address Where Medical Claims Must Be Submitted







Participant History: Past & Present Medical Problems

If you answer past or yes” to any of the items, please explain below.  Past means anytime longer than 6 months ago. Include the following:

■  Specific symptoms that are occurring     ■  How long symptom/condition lasts 

■  Date of last occurrence                           ■  How often symptom/condition occurs    

■  How you care for symptom/condition      ■ Any restrictions


General


Head






















Respiratory



Shortness of breath, etc.




If you have any history of asthma/COPD, you MUST COMPLETE ASTHMA ACTION PLAN. Date of last episode?

If you have any history of asthma/COPD, you MUST COMPLETE ASTHMA ACTION PLAN. Date of last episode?




Asthma Action Plan
Travel and change of lifestyle can cause asthma symptoms to flare up. Therefore, we REQUIRE that all Trek Participants with any history of asthma complete the Asthma Action Plan. This is a written plan that you develop with your doctor to help control your asthma. The asthma action plan shows your daily treatment, such as what kind of medicines to take and when to take them. Your plan describes how to control asthma long term AND how to handle worsening asthma, or attacks. The plan explains how to respond in the field and when to see a doctor.
Cardiovascular




















Gastrointestinal












Type_____________ When ______________ If yes, provide results of hepatitis B surface antigen test
Genitourinary













Type? When?

Musculoskeletal


















Skin




Emotional
















Hematologic




Endocrine








Gynecological (Women Only)


Severe


Allergies
Include allergies to medicine, foods, insect bites/stings, environmental, etc.


Please Check a Box For EACH Allergy
Allergy



if any



if any



if any



if any



if any
Medications You Are Currently Taking
List ALL prescription medications, over-the-counter, inhalers, and herbal supplements, etc. that you are currently taking. If psychiatric medication, please note any medications taken or changed within the past 3 months.


Please Check a Box For EACH Medication
Medication

























Hospitalizations/Surgeries/Emergencies/Urgent Care
List any hospital, psychiatric, or urgent care visits within the past 1 year


Please Check a Box For EACH Hospitalization/Surgeries/Emergencies/Urgent Care visit
Hospitalizations/Surgeries/Emergencies/Urgent Care















Immunization
buildOn advises Trek participants to obtain vaccinations as recommended for international travel by the Center for Disease Control: www.cdc.gov.  See Vaccination & Medication Form and consult with an international travel practitioner to determine what vaccinations you or your child will need.
Personal History







Lifestyle












Summary of Present Health
Please provide a general overview of the condition of your overall health and include a brief statement about your medical history and progressions of any major health issues.

Page 2

Trek Covenant

The purpose of a buildOn Ambassador Trek is to allow individuals to:

·         Participate in the construction of a buildOn school in one of the buildOn project countries;

·         Be immersed in, and learn about a new and different culture;

·         Return the knowledge gained from the Trek experience to participants’ home communities.

 

Participant commitments:

·         Raise the necessary funds to build the school and cover all travel costs associated with the trip

·         Read the buildOn Trek guide and complete assigned homework

·         Follow buildOn’s “Guidelines for Responsible Trek Travel” as outlined in the Trek Guide

·         Respect buildOn’s “Trek Methodology” as outlined in the Trek Guide

·         Complete necessary paperwork according to the timeline in the informational packet

·         Live in a rural village and participate in the cultural exchange including:

- Living and working alongside the villagers to build their school

- Eating local foods

`                       - Sharing with the community and respecting the local culture and people

·         Obtain a valid U.S. passport, necessary immunizations, and visa (where applicable) prior to departure

·         Act as unofficial ambassadors for the United States and buildOn while in the country you are visiting


buildOn commitments:

·         Provide a Trek coordinator and translator to accompany your group

·         Arrange host families and supply food and a cook in the village

·         Arrange accommodations and transportation to/from the village

·         Purchase emergency evacuation insurance for participants and provide a vehicle for emergencies to stay in the village at all times

·         Coordinate travel dates with school groundbreaking and construction

·         Offer support throughout the fundraising and pre-Trek process, including assistance with paperwork and visas and all other logistics

 

 

 

I, undersigned, agree to the above-mentioned conditions for my participation as a team member on buildOn’s Trek for Knowledge.



Page 3

Trek Gift Policy

When faced with the extreme poverty you are likely to see in the village, it is natural to want to help.  However, it is important to remember that you have already given something of great value to every person in the community.  The school (and the emphasis on the importance of education that comes with it) is a lasting gift that, over time, will break the cycle of poverty, illiteracy and low expectations in your village. 

 

buildOn strives to keep the focus of our work on building schools that will last for many generations and be part of a sustainable solution to the problems of the developing world.  Although you may be tempted to help people in the community meet their most immediate needs with some extra financial support, we ask that you help keep the focus on education too. 

 

Absolutely, under no circumstances, can you give money to anyone in your host family or community, or send money to them after your return to the US. 

 

buildOn takes great pride in our method of working with the community and asking community members to provide the unskilled labor necessary for the construction of their school.  If any money is left for anyone it may be confusing to other community members or even other villages throughout the country.  Not only can this cause controversy and conflict within the village, it can also create more work for our international staff when past and future project villages ask for money too.  In some of the places that we build, buildOn is struggling to overcome decades of irresponsible aid work that has led to a culture of dependency.

 

Our Trek Gift policy also extends to promising to send supplies or materials, because such material aid will not be sustainable and it will send conflicting messages about what buildOn provides.  Remember that you are traveling as a representative of buildOn, and buildOn is working to empower communities to develop a greater sense of self-reliance.  By promising to send supplies and materials, you could be unintentionally promoting a sense of dependency, which could damage buildOn’s work abroad.  This policy does not apply to sending letters or photos.    

 

If you are motivated by your experience to continue supporting your host village, please speak with your Trek Coordinator about more sustainable ways to give.   buildOn appreciates your help to support our mission, which focuses on the importance of education to increase independence in the communities where we work.

 

I have read and agree to abide by buildOn’s Gift Policy during and after my Trek. 



Page 4

buildOn Site Return/Extension Policy

buildOn understands the bond that develops during a Trek between Trek participants and village community members is powerful and long-lasting.  Trek participants will often desire to return to his or her Trek community to see the progress of the school and visit his or her host family.  As a result, buildOn wants to make you aware of the following guidelines to protect buildOn from liability, to promote safe and responsible travel, and to ensure respect of buildOn’s methodology.

 

·         buildOn is unable to offer support to Trek participants to either return to his or her Trek village or to stay beyond the scheduled time of his or her Trek unless the return is organized as a new buildOn Trek for a new school within the same village.

·         Any advice or support provided by buildOn staff or contractors to Trek participants to return or remain in a buildOn village, unless the return is part of a new Trek for a new school within the same village, is done independent of buildOn, and buildOn will remain free of any liability or injury that may occur as the result of said advice or support.

·         Any Trek participant who chooses to return or remain in a buildOn village understands that he or she, although independent from buildOn, will still be seen by the village as a representative of buildOn and therefore agrees to abide by the same policies and guidelines outlined during his or her Trek, including, but not limited to buildOn’s Gift Policy and the “Guidelines of Responsible Trek Travel”.

We hope that you find a buildOn Trek to be an unforgettable cross-cultural experience and will feel empowered to continue supporting the development of education in our partner countries.  buildOn has been focused on our mission to provide education to some of the poorest countries on the planet since our incorporation in 1991, and we greatly depend on the reputation we have developed as the result of our self-help methodology.   We thank you in advance for continuing to honor our history and respecting the methodology we have developed if you remain in touch with buildOn communities so we may continue to build schools until there is no longer a need. 

 

By signing below, the undersigned, understands and agrees to abide by the foregoing policy.



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