Amizade Participant Information Form
Thank you for your interest in serving and learning with Amizade and our global network of community partners. Please contact the Amizade office at 412-586-4986 or servicelearning@amizade.org for any questions.
Participant Name
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Last Name
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Group Program Number
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Program Location
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Birthdate
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Gender
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Male
Female
Other
Preferred T-Shirt Size:
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Small
Medium
Large
X-Large
XX-Large
Email 1
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Email 2
Work Phone
Mobile Phone
Preferred Phone
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Work
Mobile
Can we text you?
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Yes
No
Permanent Address
Street Address
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City
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State/ Province
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ZIP/ Postal Code
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Country
Current Address (if different from above)
Street Address
City
State/ Province
ZIP/ Postal Code
Country
Demographics
This information is used for statistical purposes only and will not be used as a basis for discrimination.
Ethnic Group
White (non-Hispanic) or Euro American
Black, Afro-Caribbean, or African American
Latino or Hispanic American
East Asian or Asian American
South Asian or Indian American
Middle Eastern or Arab American
Native American or Alaskan Native
prefer not to respond
Other
Annual Household Income
< $20,000
$20,000 - $40,000
$40,000 - $60,000
$60,000 - $80,000
$80,000 - $100,000
$100,000 - $150,000
$150,000 - $200,000
>$200,000
Which of the following best describes your home community?
Urban
Rural
Suburban
Other
Educational / Occupational Information
Are you currently a student?
Yes
No
If yes, please indicate your Current Academic Status:
5th or 6th grade
7th or 8th grade
High School Student
High School Graduate
1st year university student
2nd year university student
3rd year university student
4th year university student
Bachelor's Degree
Master's Degree
Doctorate
Other
What is the highest degree or level of school you have completed? If currently a student, highest degree received.
No formal schooling
Primary school to 8th grade
Some High School, no diploma
High School Graduate, GED or equivalent
Some college credit, no degree
Trade/ technical/ vocational training
Associate degree
Bachelor's degree
Master's degree
Professional degree
Doctorate degree
Other
Are you first generation college graduate?
Yes
No
Other
Current Employment Status:
Part-time employment
Full-time employment
Self-employed
Not employed, but looking for work
Not employed, and not looking for work
Other
Have you participated in an Amizade program before?
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Yes
No
If yes, which Amizade sites did you visit and in what year?
Do you speak a language other than English?
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Yes
No
If yes, which language(s) and what is your proficiency level
How did you hear about Amizade?
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Current or Past Participant
Friend/Family
Amizade Staff Person
School
Media/News
Facebook, Twitter, or Linkedln
Google, Bing, Yahoo, or other search engine
Other Internet/ Website
The Global Switchboard
Other
If you were referred, who referred you to Amizade?
What is your interest in this program?
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Have you ever been convicted of a crime?
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If yes, Please briefly describe the nature of the crime(s), the date and place of conviction, and the legal disposition of the case.
Health and Medical Information
The purpose of this form is to help Amizade be of maximum assistance to you before and during your Amizade Program. Mild physical or psychological disorders can become serious under the stresses of life in an unfamiliar environment. With this form, we would like to create an awareness of any health issues that you should take into consideration before going traveling. The information provided will be used to best advise you regarding the program which you will attend and the extent to which the host institution and communities can accommodate your needs i.e., the extent to which the nature or degree of a condition may prevent your successful participation in a program, whether or not appropriate medical care for the medical condition is available in the location of the program, and/or the degree to which the living and environmental conditions to which you could be exposed would present a risk to your health or the health of others.
Signature (Type initials)
*
Are you FULLY vaccinated* for COVID-19? (*Being vaccinated for COVID-19 is a requirement for all Amizade programs. When on your Amizade program you will be required to travel with the card.)
Yes
No
If you don't have your COVID-19 vaccine, please explain.
Dietary Information
Dietary Restrictions
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Vegan (I do not eat any animal products including meat, eggs, or dairy)
Vegetarian (I do not eat any meat)
Pescatarian (I do not eat meat but I do eat fish)
No Restrictions
Other
Please list any food allergies
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General Medical Information
Are you a smoker?
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Yes
No
Occassionally
Please list all allergies (Complete with NONE if this does not apply)
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Please list all allergies to medications
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Do you have a medical condition that warrants maintenance medications or physician follow-up?
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Yes
No
If yes, please describe any medical condition that warrants maintenance medications or physician follow-up
Please list any medications (both prescription and/or over the counter) you will be taking on the program and what conditions they are treating
*
Do you have a medical condition that is stable now, but may recur while traveling?
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Yes
No
If yes, please describe any medical condition that is stable now, but that may recur while traveling
Have you ever had a convulsion, seizure, epilepsy, neurological condition, or brain infection?
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Yes
No
If yes, please describe any history of convulsion, seizure, epilepsy, neurological condition, or brain infection? Please include any treatment if any
Are you currently being treated for any psychological or emotional issues?
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Yes
No
If yes, please explain any psychological or emotional issues that you are currently being treated for?
Have you ever been treated by a psychiatrist, psychoanalyst, psychologist, or other therapist for any mental, emotional, or nervous disorder?
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Yes
No
If yes, please explain any mental, emotional or nervous disorders that you have been treated for?
Please describe any medical conditions or other circumstances that the program coordinators should know before acting on your behalf in a medical emergency?
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Is there any other condition that you have that would restrict you from any physical or recreational activity?
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Are there any other need/issues that you would like to share?
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By checking this box, you confirm that you have health insurance in the United States and that you'll bring documentation of that health insurance on the program
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I certify that I have health insurance in the United States and will bring documentation of it on the program.
I certify that all responses made on this Health and Medical Information form are true and accurate, and that I will notify Amizade hereafter of any relevant changes in my health that occur prior to or during my program.
Name
For the Questions Above:
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I certify that all information on this application is correct to the best of my knowledge.
Signature
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Emergency Contact Information
First Name
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Last Name
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Relation
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Phone
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Email
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Street
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City
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State/Province/Region
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Zip Code
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Country
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Emergency Contact 2
First Name
Last Name
Relation
Phone
Email
Street
City
State/Province/Region
Zip Code
Country
Privacy Policy
For more information about our Privacy Policy, please visit the this page: https://amizade.org/privacy-policy/
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I agree to the terms and conditions outlined in Amizade's Privacy Policy.
Submit
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