Application and information

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Volunteer trip packet- total.doc

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GUATEMALA DENTAL CLINIC APPLICATION

Thank you for your interest and commitment in our program to bring dental care to Guatemalan scholarship girls and the impoverished villagers in the Coatepeque-Colomba area. Your work will make a difference to these very grateful students and adults. Our primary goal is to preserve teeth and hope to only pull teeth that are beyond saving. We are also bringing dental hygiene and training to these people. This will include a new part of the program to bring low cost toothpaste and brushes to the people.

Your commitment will be for 5 working days with 4 optional travel days. When you have decided you want to join a team, we need the following:

Travel dates____________________________________________________

Do you intend to join us for the clinic only or clinic plus travel days?

Your specialty (DDS, hygiene, asst)_______________________________

Professional _____ Student ____ (final year only please)

Level of accommodation (see trip page, dentalcare-vols.org)________ Cost__________

Trip deposit of $300 made out to Spirit Education Foundation (tax deductible 501(c)3). The remaining fee amount will be due by May 15^th . 2008 or December 1, 2008 *

Liability release form

Copy of your professional credentials (for Guatemalan approval), passport and plane ticket (when available)

Name, address and phone number______________________________________________

* Deposit is non-refundable after May 1st & December 1st  Your chosen trip cost includes all meals, lodging, ground transportation and entrance fees. This does NOT include your plane ticket, alcoholic beverages and personal purchases. (The cost of airfares will vary greatly, depending on time of purchase & route.)

Should you decide to leave the team for you own private travel plans, there will not be a refund, as reservation deposits will have been made on your behalf.

Sincerely

Pam Novak

1.  I, ___________________________________, acknowledge that  I have voluntarily applied for a volunteer position through An Arizona 501c3 non profit organization, SPIRIT EDUCATION FOUNDATION ('SEF").

2. I have read and understand the information contained in the letter I received for volunteers.

3. I understand and agree that my participation in the Program will not create an employment agency relationship with SEF or any of its sponsors or donors:  none of which assume any
responsibility for my rendition of medical care while participating in the Program.

4. I understand that I am to assume the full cost for the expenses of the trip.

5.  I am aware that working in developing countries is or may be a hazardous activity.  I am voluntarily participating in this activity with knowledge of the danger and risks involved and
agree to accept any and all risks of illness, injury, or death.

6.  I will continue to consult with the US State Department for (www.state.gov)  and the CDC (www.cdc.gov) for advisories.

7.  I understand that travel-evacuation insurance is available at www.internationalsos.com and I have the option to purchase it.

8.  I have read and understand the dental trip information found on www.spiriteduc.org

9. In consideration of my agreement to participate, I agree that:

I will not make a claim against or sue SEF, its successors, assigns, officers, directors, sponsors, or donors for illness, injury, or damage resulting from my participation in the
program or the acts or omissions of SEF, its officers, directors, sponsors, or donors.

I hereby release SEF, its successors, assigns, officers, directors, sponsors, and donors from all actions, claims, rights, demands, damages, obligations, and liabilities that I may
have or incur from illness, injury, or damage with respect to my participation in the Program.

I agree to allow myself to be photographed or video recorded while participating in the Program.  I also agree to allow any such photographs or video footage to be used by SEF
for any purpose.

I agree to provide a written critique of my participation in the Program with suggestions to improve the program.

10.  The provisions of the Agreement and Release from Liability shall be binding upon my successors and assigns.

11.  I have carefully read this Agreement and Release from Liability and fully understand its contents.  I am aware that this is a release of liability and a contract between SEF and me.
I am signing this agreement of my own free will.


Date:  _______________     Participant:  __________________________
EMAIL____________________________ Phone ____________________

Emergency Contact: __________________________________________________________

Pamela C. Novak: Founder
Spirit Education Foundation, 15532 E Tepee Dr, Fountain Hills AZ 85268

www.spiriteduc.org email:  info@dentalcare-vols.org

ph. 480-836-9946

I look forward to working with you and sharing the wonders of Guatemala, a very special place and very special people.