Registration: UCLA-- Dom. Republic-- Registration and Payment Deadline 10/16/17 (12-16-2017 - 12-23-2017 )
USER INFORMATION
First Name:   *  
Last Name:   *  
Organization/School:   *  
Classification (year in school, graduate, other):   *  
Address:   *  
City:   *  
State/Province:   *  
Zip / Postal Code:   *  
Email   *  
Confirm Email  *  
Phone:   *  
Gender:   *  
Birthdate (mm/dd/yyyy):   *  
Passport Number (if available):
Passport Issuing Country:   *  
My passport is valid for at least 6 months AFTER departure date or I will have a new passport before departure:   *     Yes  
Please enter contact information for 2 people we can contact in case of an emergency (Names, Relationship, email, telephone):   *  
Please enter any special dietary needs (vegetarian, etc.):
For emergency and planning purposes, please list any significant medical history, medications you are taking or known allergies:
STUDENT PARTICIPATION AGREEMENT

All persons/students participating in any travel program of Global Medical Training, hereafter referred to as "GMT", must accept the following statements:

1. I do voluntarily and without reservation on behalf of myself, my heirs and my estate, release and discharge absolutely and forever, GMT, and any of its agents or program partners, and waive all claims, demands, of whatever nature for any injury, loss, damage, accident, delay, actions or cause of action, known or unknown, which I now have or may acquire in the future, irregularity or expense arising out of or directly or indirectly relating to my participation in a GMT program, and arising from the use of any vehicle or services, strikes, war, acts or terrorism, weather, sickness, quarantine, government, airline, buses, transporting company, firm, individual, or agency. I understand the terms of this Release and the consequences of it and acknowledge that I have not executed it under duress.

THIS IS A RELEASE.

2. I grant GMT, or one of its agents, full authority to take whatever action they feel is warranted regarding my health and safety and that they may arrange medical treatment for me, at my expense and that if deemed necessary by the GMT personnel and/or local medical authorities, I will be sent back to the United States at my own expense for further medical treatment.

3. I will comply with all the required visas and international travel documents requested by authorities in destination and transit countries in which I travel, as well as their expiration dates for both passports and Visas. All passports must not expire any sooner than six months after the trip date. I understand that failing to comply will result in trip cancellation at my own expense.

4. If I cancel my trip for any reason or fail to comply with any international travel regulations, THERE WILL BE NO REFUNDS. However, you can make a written e-mail request that 80% of your paid amount be applied, as partial payment, to any future GMT trip of your choice. You must pay the balance between this forwarded amount and the future trip actual posted cost on the GMT website when you register for that trip. The other 20% will be used by GMT to pay for reservations and services that were covered in advance for you on this cancelled trip.

5. I understand this is a supervised program and agree to uphold individual and group standards set forth by GMT personnel. These standards include: -No alcohol abuse or any illicit drugs. -No females in male sleeping area and vice versa. -A midnight curfew applies for the entire trip. -No trip extensions or on-site visits by friends/family not previously planned/authorized by GMT. -Students with special diet requirements must bring their necessary dietary supplements. -If I have any reason to leave the trip group, I must first obtain the permission of a responsible GMT staff member. This is for safety reasons.

6. If my conduct is deemed incompatible with the interests and the standards of the group and if my enrollment is TERMINATED, no refunds can be expected and returning to the United States is at my own expense. A verbal warning will be provided prior to expulsion from the program. A written report will be provided later.

7. I understand this is NOT a tourist-type program, but is an international humanitarian team effort serving disadvantaged people in sometimes remote and difficult circumstances which, on occasion, may include travel over long distances, on land, air and water, on safe transportation.

8. I grant GMT permission to reproduce photographs or movies, of me taken during the period of time that I am participating in this program, including written statements I may make concerning this program.

9. The calendar deadline for all GMT trip applications and all GMT trip payments is eight (8) weeks before the beginning trip date for which you have applied. Our staff needs this to finalize reservations and services for you. When you submit an application, you will be placed on the ''applied for'' list for that trip. When you submit your payment you will be placed on the ''final trip list''.

10. I declare that I am not addicted or habituated to the use of non-/or prescription mood altering drugs/chemicals, including alcohol, and will not seek these drugs while on a GMT trip.

11. A midnight curfew applies for the entire trip for safety reasons. This means that all trip participants and GMT staff must be inside our hotel before midnight and remain there the rest of the night.

12. No alcohol abuse or any illicit drug use will be allowed. If this is violated, the participant(s) will be specifically warned, verbally and in writing, and a second violation can result in a dismissal of that participant from the remainder of the trip. There will be no refunds and any additional related expenses will be paid by that trip participant.

13. Travel and health insurance is the responsibility of each trip participant.

14. All GMT website posted trips begin at 12:00 AM on day one and end at 12:00 PM on the last posted day of the trip. Any trip participant activities either before or after those times are not the responsibility of GMT. This includes any tours, visits or sightseeing that I may elect to do in the trip country or elsewhere. I do those things upon my own initiative and responsibility and at my own risk, whether before or after the GMT trip.

Please show this agreement to your parents or any other person(s) who may feel a shared responsibility for your well-being.


BE SURE TO MAKE YOUR OWN COPY OF THIS AGREEMENT FOR YOUR RECORDS

I have read and accept this agreement:   *     Yes  
Enter the Security Code   *  
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My favorite patient memory was a home visit we took in Granada. The woman was very old, almost blind, and lived on her own. She welcomed us into her home and was very giving about information regarding her personal and family life. This opportunity allowed me to see first hand the kind of health care that is available to these people and made me fully appreciate everything GMT does and stands for. Here the doctor taught us about not only the health of the patient, but also about the way of life of many Nicaraguan individuals. It was truly incredible.- Heather Berman, Junior, University of Florida