Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

Please list your primary phone number.

(###)

###

####

Volunteer Trip that I am applying for *

Kenya/Tanzania 2024

Peru (on hold)

Unsure

Year applying for: *

2024

2025

I am in good health and I understand the rigors of a volunteer trip. I understand that I may have to withstand extreme temperatures, missed meals, long travel hours and possible exposure to tropical diseases. *

I agree

I have some limitations, but will still be able to manage the rigors of the trip.

I disagree

I understand that I will need to get medical clearance from a licensed physician, nurse practitioner or physician assistant before in order to participate in a volunteer trip. *

Yes

Not Applicable as I am volunteering in the USA

In order to go on a volunteer trip as a CUW NP student I understand I need to have completed at least 1 clinical course. *

I will have completed 1 clinical class.

Not applicable as I am not a NP student.

I understand that once I pay my trip fees they are non-refundable. *

Yes

Not applicable as I am volunteering in the USA

COVID Vaccine requirement *

I understand that HWB REQUIRES all volunteers to be fully vaccinated against COVID before they travel internationally and I will be fully vaccinated against COVID before I travel with HWB.

I am already fully vaccinated against COVID-19

I understand that if I am not fully vaccinated against COVID I will not be able to travel internationally with HWB.

I agree to make arrangements to attend the mandatory team meetings. If I reside outside of Wisconsin I will attend the meetings via Zoom. *

I will attend in person

I will attend via Zoom

Not applicable as I am volunteering in the USA

I understand that if my body size exceeds the seat size limit set by the airlines I may need to purchase an extra seat for an additional fee. *

Yes

Not applicable as I am volunteering in the USA

I have not been convicted of any violent crime. *

I have not been convicted of a violent crime

I have been convicted of a violent crime

Application fee *

I understand I must pay a $50 application fee. ($25 for students)

I have already paid the $50 application fee. ($25 for students)

I verify that I am 18 years of age or older.

Yes

No, but I will be traveling with my parent(s)

No, but I will be volunteering in the USA

Date

MM

DD

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