Service Trip/Internship Application

SERVICE TRIPS/INTERNSHIP APPLICATION

Fields marked with an * are required

Once completing the following application please mail a $200 non-refundable deposit to:

Compas de Nicaragua, 60 Merrimack Road, Amherst, NH 03031, USA.

Application and deposit must be received at least one month prior to date of departure. Full non-refundable trip participaton fee is due two weeks prior to departure.

Please remember to scroll down to fill out entire application

* Indicates required field

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Email *

Gender *

Date of Birth (Month/Date/Year *

Group affiliation (if any) *

Current occupation *

Service Trip Fee (Please select one of the following options) *

Internship fee (Please select one of the following options) *

FINANCIAL CONDITIONS: Compas de Nicaragua shall be paid by check in accordance with the following payment schedule: A $200 non-refundable deposit (and this online application) for each trip participant will be due one (1) month prior to the trip start date. The remaining balance of the non-refundable, all inclusive trip fee is due within two (2) weeks of the schedule trip start date. Checks should be made to: Compas de Nicaragua, 60 Merrimack Road, Amherst, NH 03031. *

I accept the financial conditions

Trip Start Date (Month/Date/Year) *

Trip End Date (Month/Date/Year) *

Emergency Contact: First and last name *

Relationship *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Email *

Describe previous international travel experience *

What skills will you be able to contribute to this service trip? *

What would you like to gain from this experience? *

Spanish speaking ability *

Please list any allergies, disabilities, or other health conditions: *

Do you have a history of drug and/or alcohol abuse? If yes, please explain: *

Are you currently under a physician's care or receiving prescribed medication? If yes, please explain: *

Additional information

Would you prefer a more comfortable or rustic living situation? *

Would you prefer a host family with children, teens, pets, farm animals? *

Do you have any dietary restrictions, allergies? Are you a vegetarian, vegan, or lactose intolerant? Are there certain foods you cannot or would prefer not to eat? Please be specific *

COMPAS DE NICARAGUA SERVICE TRIP RELEASE FORM Note: Do not electronically sign this form until you have read it carefully and understand its contents. This is a legally binding release, which may reduce or eliminate your legal recourse in certain events. I, (the "Participant") hereby request that I be allowed to participate in the Compas de Nicaragua service trip to Nicaragua sponsored by Compas de Nicaragua, (“Compas”), and as part thereof, to travel to and from the Compas de Nicaragua project—via transportation arranged by myself. Upon acceptance of my application by Compas, I agree as follows: I will, as recommended by my personal physician, secure all necessary inoculations/vaccinations prior to my departure date. I further agree that I will secure a passport necessary for foreign travel, and purchase my own comprehensive travel insurance plan. I acknowledge that I am responsible for my personal health and safety during the Compas de Nicaragua service trip. I agree that if, at any time, Compas should determine that my conduct discredits the status or reputation of Compas, I will voluntarily terminate my participation in the service project and return to the United States when directed to do so by Compas. I am now covered, and at all times while participating in the Compas de Nicaragua service trip, I will remain covered by health insurance. While Compas will use all reasonable efforts to make first aid and basic medical care available to Participants as promptly as practicable in any appropriate circumstance, Compas shall not be responsible for any major medical care or hospitalization incurred by any Participant. I confirm my agreement with Compas that the period of my participation in the Compas de Nicaragua service trip will be limited to the dates I provided on my online application. I agree to be financially responsible for all travel within the United States, to and from Nicaragua, and any travel within Nicaragua outside the dates of the service trip.I agree to allow Compas to use my name, written or oral quotations and/or photographs in marketing, training and promotional materials, including but not limited to: posters, brochures, handbooks, and web sites. I, in consideration for Compas acceptance of me in the Compas de Nicaragua service trip, hereby: 1) agree that neither Compas, nor Field Supervisors, or participants in the Compas de Nicaragua service trip (with Compas and persons referred to as an "Indemnified Party") shall be liable for any action taken or omitted to be taken by an Indemnified Party in connection with or in any way related to this Agreement or my service as a volunteer unless such action or omission constitutes willful misconduct on the part of such Indemnified Party or is adjudicated by a court of competent jurisdiction to constitute gross negligence on the part of such Indemnified Party; 2) RELEASE, INDEMNIFY, AND AGREE TO HOLD HARMLESS to the fullest extent permitted by law each Indemnified Party from and against any and all loss, claims, damages, liabilities, or actions (INCLUDING, WITHOUT LIMITATION, ANY LOSS, CLAIMS, CHARGES, LIABILITIES, OR ACTIONS ARISING OUT OF THE NEGLIGENCE OR ALLEGED NEGLIGENCE OF ANY INDEMNIFIED PARTY) in any way arising out of, connected with, or attributable to my service as a volunteer or participation in the Compas de Nicaragua service trip (including, without limitation, any inoculations, general medical treatment, or emergency medical treatment, including surgery, rendered to me in event of need); 3) acknowledge, recognize and accept that my participation in the Compas de Nicaragua service trip will involve activities in a foreign country and will likely include activities in remote and/or underdeveloped and/or politically sensitive areas which may subject me to increased risks of disease and/or injury and/or risks to my personal safety, and that medical services may not be immediately available and may not be available at a level equivalent to that in the United States. 4) agree to respect the decisions of the service trip leaders. As a responsible Participant, not a tourist, I realize that I will not be able to travel on my own during the service trip. I understand, respect and will abide by these basic rules: 1) no handling of fire arms, 2) must follow group decisions, 3) no violence in any form towards anyone, 4) no use of recreational drugs or alcohol and 5) will obey the laws and regulations of the country we will visit, Nicaragua. I certify that the above information is truthful and accurate to the best of my knowledge. By clicking "Accept" I also agree 1) to purchase my own comprehensive travel insurance plan, 2) to secure all necessary inoculations/vaccinations prior to my departure date, and 3) to all the terms set forth in the Financial Conditions and Service Trip Release Form above. *

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SERVICE TRIPS/INTERNSHIP APPLICATION

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SERVICE TRIPS/INTERNSHIP APPLICATION

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