Amazon Promise Outreach Trip Application

Amazon Promise Medical Outreach Volunteer Trip Application

Thank you for choosing to volunteer with Amazon Promise!

1. Please complete this entire Application and send it to Amazon Promise.

2. Additionally, please provide:

email a scanned copy of your current passport primary page
email a scanned copy of your Medical license or diploma/certificate
$300 deposit

Alternately you can send your application and/or supporting documentation via the following.

3. Send by mail:

OR Send by Email:

Amazon Promise
PO Box 1304
Newburyport, MA 01950 USA

Jackie@amazonpromise.org

Abigail@amazonpromise.org

Trip Policies and Cancellation Information
1. Amazon Promise Medical Outreach Volunteer Trip (Outreach Trip) dates are final. However, Amazon Promise may facilitate additional Outreach Trip for groups of 6 or more people who wish to work and travel together.
2. All deposits for trip fees are due at the time of application. Due to the impact that volunteer cancellations have on the entire Outreach Trip, trip fees are non-refundable.
3. Trip fees are due in full 45 days prior to the Outreach Trip start date. Due to the impact of volunteer cancellations have on the entire Outreach Trip, trip fees are non-refundable.
4. Amazon Promise will notify volunteers of cancellation no later than 45 days prior to Outreach trip start date.
  If Amazon Promise must cancel an Outreach Trip, it will fully refund trip fees or apply fees to another Outreach Trip within the next year at the volunteer’s discretion.
5. All volunteers who are accepted to an Outreach Trip must register with the U.S. Embassy or other relevant embassy in Lima, Peru.
*It is strongly recommended that volunteers purchase trip cancellation insurance at the time they purchase their airline tickets.
By typing my full name here and submitting this form, I Your name* acknowledge and agree that I have read, understood, and agreed with the following conditions regarding my Outreach Trip provided by AMAZON PROMISE (“AP”), which is scheduled to take place on the following Trip Dates from Date from*   toDate to*  ("Outreach Trip").

1.   I acknowledge and agree that I have been asked to consult a qualified medical practitioner regarding my ability to undertake this Outreach Trip and I have no physical or psychological condition that would preclude my participation or pose an unreasonable risk to others or myself during my Outreach Trip. I further acknowledge and agree that I am following my medical practitioner’s advice about my possible need for vaccinations and/or medication before and during my Outreach Trip.

2.   I acknowledge and agree that I have been told that my destination in the Amazon jungle is in a remote area far from modern health clinics or hospitals. If a physical or psychological condition should develop, a) AP is not responsible or liable for any delay or inadequacy in my receiving medical treatment, and b) I agree to reimburse AP for any costs incurred in connection with my evacuation and/or hospitalization.

3.   I acknowledge and agree that I have been informed and I understand that there are certain obvious risks inherent in any trip to a South American city and the Amazon jungle (including the risk of personal injury and/or death) and I freely and voluntarily accept those risks. I understand AP can neither eliminate all such inherent risks nor guarantee a traveler’s personal safety. I also understand that AP nether implies that evacuation is available or possible in the event of hostile circumstances. In the event of an emergency evacuation, I agree to reimburse AP for any costs incurred with my evacuation.

4.   In consideration for the services provided by AP in connection with the Outreach Trip, I, for myself and my executors, administrators, heirs, next of kin, successors, and assigns, hereby do and shall release, acquit, discharge, and forever indemnify and hold harmless AP, and each and every one of its directors, officers, employees, volunteers, owners, representatives and agents and their respective successors and assigns from and against any and all liability, loss, cost, damage, expense (including reasonable attorney’s fees) or other claim or action of any kind that may arise or occur on account of or in connection with the Outreach Trip, including without limitation any liability for death, disability, personal injury, property damage, property theft, any claims for negligent acts or omissions or any claims resulting from: acts of God; detentions; government restrictions; delays or cancellations beyond its control; strikes; thefts and other crimes; vehicular accidents; acts of war; civil disturbances; political unrest; sickness or infections; weather; personal mishaps such as slipping and falling; and encounters with hostile governments, individuals, wildlife, plants, and other jungle aspects.

5.   I understand that any and all film images made during the Outreach Trip in which I appear may be used for publication and/or display to promote AP’s non-profit mission and that I will receive no financial compensation for the film image used.

6.   If my financial pledge to AP has not been received in full, if my credit card is denied or my check is returned by my bank, I will be responsible for all pledge fees and costs required to fulfill my financial obligation to AP.

7.   In the event of my serious personal injury or death during the Outreach Trip, I hereby authorize and direct AP to notify the following person(s):

Personal Information
Participant's Full Name*

First NameLast Name
Participant's Birth Date*

MonthDayYear
Cell Phone Number*

Country CodeArea CodePhone Number
Home Phone Number

Country CodeArea CodePhone Number
Work Phone Number

Country CodeArea CodePhone Number
Participant's email*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Anticipated Trip Start Date

MonthDayYear
Date
I identify my gender as:

MaleFemale
Occupation*
Passport Number*
Passport Location Issued*
Passport Date Issued*

MonthDayYear
Date
Passport Expiration Date*

MonthDayYear
Date

Emergency Contact Information
Primary Emergency Contact*

First NameLast Name
Relationship*

FriendPartner/Husband/WifeFamily MemberOther
Primary Emergency Contact Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Primary Emergency Contact Phone Number*

Country CodeArea CodePhone Number
Primary Emergency Contact Email*
example@example.com
Secondary Emergency Contact

First NameLast Name
Secondary Emergency Contact Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Secondary Emergency Contact Phone Number

Country CodeArea CodePhone Number
Secondary Emergency Contact Email
example@example.com

Insurance Information
Insurance Company Name
Personal Health Insurance Policy Name and Number*
Does it cover international travel?*

YesNo
I understand I must purchase my own medical/evacuation insurance and submit a copy to Amazon Promise 45 days before departure (Choose your own insurance or try either United Healthcare Global Safe Trip uhcsafetrip.com or SOS travel insurance internationalsos.com/personal-membership)
Medical/evacuation insurance acknowledgement*

Understood

Outreach Trip Payment

A deposit of $300 is due at the time of application. The trip balance is due no later than 45 days prior to departure date. I will pay my deposit via the following:
Deposit Payment Method*

I have mailed in my deposit of $300usdI have paid my deposit via PayPalI have paid my deposit via SquareOther
Please mail any check payments (in U.S. Dollars) to:
AMAZON PROMISE, PO Box 1304, Newburyport, MA 01950 USA

Medical Information
Medical Information - Name*

First NameLast Name
Your Medical Information
Please list any medications you will be taking:*
Do you have any medication or environmental allergies?*
Please describe any health conditions or physical limitations you have:*
Your Immunization Information

Malaria is endemic in the Amazon Basin region in which you will be working. Malaria prophylaxis is strongly recommended. It’s very important that you consult with a qualified medical practitioner before undertaking an Amazon Promise Outreach Trip. Be sure to review ALL recommended vaccinations and medications with your practitioner.
Immunization Confirmation*

Yellow FeverTyphoidPolioHepatitis AHepatitis BDiphtheria / TetanusMeningitisRabiesOther

Agreement Acknowledgement
I, the participant hereby attest that I have carefully read this Outreach Trip Application and Permission to Participate, understand its contents, and agree to its terms and conditions. Submission of this form is my acknowledgement of this agreement.*

I agree
Submission Date*

MonthDayYear

Survey

To help us maximize your experience, please answer the following questions:
What attracted you to this project?
It is not unusual for plans to change during the course of an Outreach Trip. How flexible are you to changing circumstances and conditions? How do you cope with last-minute change in plans?
Flexibility
What travel experience have you had in third world, primitive wilderness conditions? (Including lack of toilet facilities, plentiful insects, close camping conditions with little privacy, very hot, humid, or torrential weather.)
Wilderness
Outreach Trip teams rely strongly on interdependence, with each team member contributing a vital service to the Outreach Trip's function. This requires doing your job well and trusting others to do theirs. Do you work well in a team environment? How do you handle conflict?
Interdependence
For medical volunteers:
- Have you worked without access to lab and x-ray facilities?
- Have you worked with limited supplies?
- Have you had experience examining multiple family members at one time?
Medical Volunteers
What do you expect from your Amazon Promise Outreach Trip?
Your Expectations for participation in an Outreach Trip
How did you hear about Amazon Promise?*

FriendAlumniSearch EngineVolunteer WebsiteWebsiteOther
If you require a copy of your form please use the print form button prior to clicking on the submit button.

If you require any changes to what you have submitted after clicking on the submit button, please email Jackie

An email with the submission details will be sent to you as part of the process.
Should be Empty:

Amazon Promise Medical Outreach Volunteer Trip Application

Trip Policies and Cancellation Information

Personal Information

Emergency Contact Information

Travel Information

Insurance Information

Outreach Trip Payment

Medical Information

Agreement Acknowledgement

Survey