VOLUNTEER 1 2 3 4 5 6 Which trip will you be attending?*Montecristi, January 13 - 19, 2019Juan Dolio, March 17 - 23Juan Dolio, April 28 - May 4Samaná, May 26 - June 1Cabrera, Jun 30 - July 6Jarabacoa, August 25 - 31Last Name*First Name*MIDate of Birth*Sex*MaleFemaleOtherEmail* T-Shirt Size*SML Current Home Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Passport #*Mobile Phone*Home PhoneEmergency Contact*RelationshipEmergency Contact Phone* Current Occupation*StudentEmployedOtherEmployed byWill this be your first trip with Bright Island Outreach?YesNoWho is your primary contact in Bright Island Outreach?Name of your group/organization (if applicable)?List any family members traveling with youPlease rate your proficiency in Spanish (circle one)*FluentWorkplace-ProficientConversationalBeginnerNonePlease provide some information about yourself (background, interests, hobbies, etc.)Please list any health issues that we should know aboutOur expeditions, at times, require a high level of physical demand and the weather can be hot and humid. Any information that would be useful for our team to know about will help us to better accommodate your needs (Allergies, physical limitations, asthma, pace maker, etc.)Briefly describe your own objectives and expectations for this vision/mission trip WAIVER OF LIABILITY (please read carefully) I certify that my answers are true and complete to the best of my knowledge. I understand that any falsified statements on this Application, or omissions of fact, either on this Application or during the pre-departure process, will result in my application being rejected. I acknowledge that my purpose in participating in this expedition is to learn more for the ultimate purpose of supporting the people of the Dominican Republic, and more specifically the beneficiaries of the programs. In respect for my hosts and the beneficiaries, I will make effort to communicate any changes to my travel plans or schedule with the greatest advanced notice possible.ASSUMPTION OF RISKS (type initials below)*I acknowledge that travel to, from and within any foreign country contains risks and potential losses and I assume all responsibility for myself and accompanying family members during my trip. Therefore, I release Dr. Eric Harris, and other expedition coordinators from any liability or damages.PHOTOGRAPHY/ VIDEO /UPDATES CONSENT (type initials below)*I grant permission to Dr. Eric Harris and other participants or representatives to take photographs and video of me and to use, edit, publish and reproduce all images and videos of me for promotional and marketing purposes, fundraising, and other publications or presentations sponsored by Dr. Eric Harris or his affiliates, without restriction and without compensation to me. I release Dr. Harris from all claims and liability with respect to any photographs or videos of me that they take, use, edit, publish, or reproduce.ACKNOWLEDGEMENT OF UNDERSTANDING (type initials below)*I have read this agreement, fully understand its terms, and I understand that I am giving up substantial rights, including my right to sue. I acknowledge that I am signing this agreement freely and voluntarily, and intend this agreement by my signature to be a complete and unconditional release of all liability of BRIGHT ISLAND OUTREACH.Please type full name* First Last Signature (full name)*Date Signed* Liability Waiver and Assumption of Risk As you travel abroad, you are representing your family, your school, your community, and your country. The key to a successful trip is your open-mindedness and willingness to accept new cultures and the occasional inconveniences of international travel. If you keep your eyes and your mind open, you will bring home something of lasting value. The purpose of Bright Island Outreach is to attend to the needs of global communities that have little or no access to oral health care while providing health care professional school candidates with opportunities to experience and contribute to communities in need. It is in this spirit that we make this assumption of risk agreement for this trip. Event Description: Humanitarian Trip in Dominican RepublicPersonal Responsibility (type initials below)*I (undersigned name) understand that my participation in the 2016 Dominican Republic Humanitarian Expedition is subject to all of the following conditions, promises, agreements, and understandings. By signing this Release and Assumption of Risk Agreement, I understand that I am (1) agreeing to all of the following conditions and agreements; (2) making the stated promises; and (3) have the following understandings. I am solely responsible and liable for (1) obtaining all personal documentation appropriate for this trip including but not limited to, international passports and other forms of government issued identification; (2) paying all costs and expenses related to my participation in the program; (3) I am responsible for my punctuality, personal conduct, and personal belongings while traveling and (4) that the program is not responsible for the products or services provided by the host organization or the proper performance or presentation of their duties, obligations, products or services.Student Conduct Code (type initials below)*I acknowledge that I have been advised regarding the Student Conduct Code associated with my affiliated educational institution and agree to abide by that code while participating in the program/trip. Further, I agree and pledge that I will comply with all regulations and directions given me by staff members while participating in the program, including University officials, volunteers and employees of the host organizations, and all other officials acting within their official capacities. I agree that I will comply with all applicable laws of the jurisdictions in which I travel and will not engage in any conduct or behavior that causes potential harm to myself or others, or is disruptive to the trip, the sponsoring organization, the educational institution, or the organization hosting our stay.Damages Waiver (type initials below)*In consideration of approval for my personal attendance at the above-mentioned activity, I, for myself, my heirs, executors, administrators, and assigns, do waive, release, and discharge any and all rights, demands, or claims for damage and cause of suit or action known or unknown, that I may have against the State of Arizona, the affiliated educational institution, the sponsoring organization or their employees or agents for any or all injuries in any manner resulting from the above referenced class. I hereby authorize the event manager or their designee to request medical assistance as they find necessary and further attest and verify that I have full knowledge of all risks involved in this activity and that I will assume and pay my own medical and emergency expenses in the event of accident or illness regardless of whether I’ve authorized such payments.Participation Termination (type initials below)*I understand and agree that the sponsoring organization and its affiliates shall have the right to enforce appropriate standards of conduct, and that they may at any time terminate my participation in the program/trip for failure to maintain these standards OR for any actions or conduct which the sponsoring organization considers to be incompatible with the interests, harmony, comfort, and/or welfare of the program and other participants. If my participation is terminated, I understand that I will be sent back at my own expense and with NO refund of any fees or costs.Medical Treatment (type initials AND select below)*I AGREE, REPRESENT, and CONSENT that in the event of any medical emergency I do / do not (select one below) authorize and consent to any x-ray examination, anesthetic, medical, dental, or surgical diagnosis, treatment or hospital care that Bright Island Outreach and/or its affiliates (including the organization advisor, program director, participating officials, or agents) deem necessary for my safety, health, or protection, and I FULLY RELEASE each of them from any liability for such decisions or actions taken in this regard. This consent includes, without limitation, an authorization to place me in a hospital for medical services or treatment or in the care of a local medical doctor. I certify that to my knowledge I have no medical conditions that would adversely affect my participation in the program.Medical Treatment (please select one)*I DO consentI DO NOT consentRefunds (type initials below)*I understand that the sponsoring organization reserves the right to make changes in cases of emergency or changed conditions or in the interest of the group. Any refunds necessarily prompted by any such actions will be determined in each individual case at the sole discretion of the sponsoring organization.I have read this Release and Assumption of Risks Agreement respecting the Humanitarian Trip in the Dominican Republic and understand and appreciate the risks I am assuming and voluntarily sign this Agreement to evidence my agreement to its terms and conditions.Printed Full Name*Signature*Date Signed* Journey type*Hold my spotSign me up!PhoneThis field is for validation purposes and should be left unchanged. 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