Trip Participant Information First Name(Required) Middle Name Last Name(Required) Which trip are you interested in?(Required)Cote d’Ivoire: February 21 – March 2, 2025Guatemala: May 9 – May 16, 2025Uganda: June 4 – 17, 2025If you're interested in other trips, please list them here. Email(Required) Phone Number(Required) Date of Birth (MM/DD/YYYY)(Required) MM slash DD slash YYYY Biological Sex(Required) Nationality(Required) State of Residence(Required) Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAndorraAngolaAnguillaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire - Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandColombiaComorosCook IslandsCosta RicaCôte d’IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDemocratic Republic of the CongoDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFijiFinlandFranceFrench GuianaFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHoly SeeHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorth KoreaNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian TerritoriesPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRepublic of the CongoRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSão Tomé and PríncipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSomalilandSouth AfricaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands - BritishVirgin Islands - U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Shirt Size(Required)Adult XSAdult SAdult MAdult LAdult XLAdult XXLWhich airport would you be departing from?(Required) What is your specialty area of expertise? Include your degree acronym.(Required)How could your skillset best be used in an international clinic setting?(Required) Please tell us about your international travel experience to developing countries, if applicable.(Required)Indicate language skills and proficiency level. Please share your reasons for wanting to participate in Project C.U.R.E.'s travel program.(Required)Are you a returning Project C.U.R.E. international travel participant?(Required) Yes No Please list any health conditions or limitations (if none, put "N/A").(Required)Are you currently under a doctor's care?(Required) Yes No Are you currently taking any medications?(Required) Yes No If you answered "yes", list medications here: Do you have any dietary requirements? If so, please list:(Required) Each volunteer is expected to function as a team member and adapt to unexpected circumstances. Please give at least one example of your ability to work as a member of a team and how you were able to adapt to a changing environment.(Required)International trips can be emotionally and physically challenging.(Required) Yes, I can cope with such challenges. No, I cannot cope with such challenges. Emergency Contact Name(Required) Relationship(Required) Emergency Contact Phone Number(Required) Emergency Contact Email(Required) Emergency Contact Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAndorraAngolaAnguillaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire - Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandColombiaComorosCook IslandsCosta RicaCôte d’IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDemocratic Republic of the CongoDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFijiFinlandFranceFrench GuianaFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHoly SeeHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorth KoreaNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian TerritoriesPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRepublic of the CongoRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSão Tomé and PríncipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSomalilandSouth AfricaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands - BritishVirgin Islands - U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country I certify that my international flight arriving in the final destination for the trip lands at or before the required time as indicated on the "Suggested Flight Itinerary" document. I agree to meet the trip leader at the baggage claim of the airport, unless I am otherwise notified. If my flights are delayed for any reason, I will notify the Trip Leader and Project C.U.R.E. Travel Department as soon as possible. If I fail to arrive in-country at the required time, I will be responsible for any additional transportation and/or accommodation costs my late arrival causes.International Flight Agreement(Required) Yes, I agree. Project C.U.R.E. will provide travel insurance including medical evacuation coverage for all participants unless you specify here that you already have this coverage. Do you have international travel insurance? Yes No I understand that my participant program fees are a non-refundable donation to Project C.U.R.E. Should I need to cancel my trip, or the trip is canceled for any other reason, I understand that I may use funds paid as a credit for future C.U.R.E. Clinics.I CERTIFY that all statements and information furnished in this Statement are true, complete, and correct to the best of my knowledge and belief, and are made in good faith. I understand that statements or information furnished on this form are subject to verification and I agree to furnish supporting documents or information when so requested and/or names, addresses, and phone numbers (if known) of officials or other individuals who can substantiate the qualifications described above. I also understand that intentional misstatements or falsification will result in disqualification.Agreement to certify all statements are true, complete and correct.(Required) Yes, I agree. The information provided in this application will not be shared outside of Project C.U.R.E. Your personal health information will only be used for purposes related to function and safety of Project C.U.R.E. clinic trips. How did you hear about us? Today's Date(Required) MM slash DD slash YYYY Thank you for your interest and for applying. Your application will be reviewed and we will contact you within 2 weeks. CAPTCHA
