2015 Indonesian Health Initiative Application Indonesia
Indonesia June 6th - June 26th 2015
Sign in to Google to save your progress. Learn more
EVENT INFORMATION
For consideration as a volunteer on our 2015 Indonesian Health Initiative Trop, please read and fill out the form below.

TRIP NAME: 2015 LearnToLive Indonesian Health Initiative

PROGRAM DATE: JUNE 6th - JUNE 26th 2015

APPLICATION DEADLINE : January 15th 2015

PROGRAM COST FOR VOLUNTEER MD/RN/SKILL  - $800.00
This includes all food/lodging and transfers within country from June 6th - June 26th.

PROGRAM COST FOR STUDENT- $1500.00
This includes all food/lodging and transfers within country from June 6th - June 26th.


Look below and watch the following short films about volunteering with LearnToLive.

Questions or just wanting to say hi!
Email:  hello@learntoliveglobal.org
Call: +1 504- 475 -8033
Learn To Live - Indonesian Health Initiative & Water Project
Here's a good look at current LTL projects and the communities you will be servicing with us.
Yoga is Not Going to Cure Malaria: The Musical
Here's a quick mockumentary about what volunteering with LTL can be like!
PERSONAL INFORMATION
NAME *
(Last Name, First Name)
EMAIL *
PHONE # *
ALTERNATE PHONE #
ADDRESS *
(Street / City / State / Zip)
PASSPORT #
NATIONALITY
ISSUE DATE
EXPIRATION
PLACE OF ISSUE
DATE OF BIRTH *
HEALTH INFORMATION
AGE *
SEX *
Do you have any special dietary needs? *
(Please describe)
Do you have any special medical needs or allergies? *
(Please describe)
Are you a smoker? *
Do you get motion sickness? *
PERSONAL QUESTIONAIRE
Why do you want to be a part of LearnToLive? *
(Please describe)
What awesome skills can you bring to the LearnToLive team? *
(Please describe)
If you could go anywhere in the world, where would you go? *
(Please describe)
What are your super powers, otherwise known as strengths? What are your weaknesses? *
Do you enjoy new and exciting foods? *
(Like Large BBQ fish, fruit, satay chicken and noodles)
Are you flexible with your role within our crew? *
 (One day we may need you to work in the clinic as a pharmacist, then next day I may need you to help with the nutrition education with the kids and the next day you may need to drag wood up a hill, would this be something you can handle?)
Help us understand how you will handle the following situations: *
You've just arrived in Indonesia for your 3 week stay as a volunteer with LTL, but your baggage never left your last transit point!
*
While working at the LTL accommodation, the power has been going out on a daily basis for long periods of time. Access to the internet is sporadic and slow at night.
*
You have a four hour car ride ahead of you, up rocky and uncomfortable roads, to a remote mountain village that the project services.
Will you volunteer to carry camp/clinic supplies?
Clear selection
Are you willing to share hotel accomodations?
Clear selection
EMERGENCY CONTACT INFORMATION
Person to be contacted in case of emergency
NAME
ADDRESS
(Street / City / State / Zip / Country)
Telephone #
ASSUMPTION OF ALL RISKS AND RELEASE OF LIABILITY
I expressly recognize and acknowledge that there are numerous risks, hazards and dangers incident to the participation in any of the activities incident to the trip or outings in which I desire to participate, including hazards incident to travel in mountainous terrain, on water including rapids, the forces of nature, travel by aircraft, boat, raft, automobile, bus or other means of conveyance, the occurrence of any one of which could result in serious injury, financial loss, and disability, (hereinafter “injury” or “injuries” including but not limited to, personal injuries such as sprains, strains, broken bones, torn ligaments, pain and suffering, emotional or mental injuries, and death, as well as property damage. Such incidents may occur anywhere, including in remote or inaccessible areas without means of rapid evacuation and without the availability of medical supplies or facilities. This list is for illustrative purposes only; the Undersigned understands and agrees that this document applies to any and all injuries, which might arise from participation in outdoor adventure activities. The Undersigned does expressly acknowledge that the enjoyment and excitement of adventure travel related to medical expeditions as provided by LearnToLive, Indonesian Health Initiative, is derived in part from the inherent risks incurred by travel and activity beyond the accepted safety of life or activities at home, work or other forms of recreation or vacation.

I expressly acknowledge, recognize and voluntarily assume the risks of any injury, as well as all loss or damage, of whatever kind or character and from any cause, expressly, including any injury, loss or damage resulting in any way from any acts of omission, commission, or negligence on the part of any guides, sponsors, other participants, associates, property owners and proprietors of any of the premises used by LearnToLive, Indonesian Health Initiative and all agents, officers, directors, employees, representatives, successors and predecessors thereof, in any way arising from or related to my participation in the activities.
I further agree that all such participation shall be at the Undersigned’s own risk and the Undersigned expressly assumes the risk of any and all such injuries. The Undersigned does hereby covenant not to sue and does further expressly agree that the above persons, firms,
entities are forever released and discharged and shall not be liable for any claims and demands for injuries, damages, actions or causes of action which arise out of the Undersigned’s participation in all activities including but not limited to medical expeditions offered by LearnToLive, Indonesian Health Initiative.

In addition to expressly releasing and discharging the above, the Undersigned further expressly agrees to indemnify and hold harmless such persons, firms and entities encompassed by this agreement from any and all claims, demands, injuries, damages, actions or causes of action arising from Undersigned’s participation in the outings offered by LearnToLive, Indonesian Health Initiative, including but not limited to all attorney’s fees, costs, expenses, damages, judgments or actions in any form.

It is agreed that this agreement shall be construed and governed in accordance with the laws of Louisiana and the Undersigned hereby consents and agrees that all disputes and matters whatsoever arising under, or in connection with, this Agreement shall be presented and resolved exclusively in a Court located in New Orleans, Louisiana.

The Undersigned further expressly agrees that any modification or revision of any provisions of this agreement must be made in writing and executed by both the Undersigned and LearnToLive, and that there can be no oral modification of this agreement whatsoever.

I HAVE READ AND CLEARLY UNDERSTAND THE LANGUAGE AND MEANING OF ALL THE PROVISIONS OF THIS AGREEMENT. I HAVE READ AND CLEARLY UNDERSTAND THE TERMS AND CONDITIONS AND FREELY AND VOLUNTARILY CHOOSE TO PARTICIPATE.
Please re-type your name *
By typing your name you acknowledge, understand and accept these risks and release liability.
TERMS AND CONDITIONS
a) CANCELLED TRIPS
LearnToLive reserves the right to cancel any trip departure for insufficient sign-up. LearnToLive is not responsible for recoverable expenses such as non-refundable, advance air tickets, insurance costs, visa fees, equipment, vaccines or any expense incurred in your preparation for a trip. The mentioned trip cancellation terms and conditions apply in case of trip cancellation by the participant or LearnToLive due to war,  government-issued restrict, advisory warnings, political unrest and/or terrorist acts or threats.

b) INSURANCE
Trip participants are strongly advised to purchase individual trip cancellation and medical evacuation insurance for the full amount of the trip. This insurance must cover including but not limited to the following: 1) all deposits and payments if you need to cancel your trip prior to departure because of illness or family emergency, 2) emergency medical evacuation; 3) payments in the event you return or your trip is interrupted due to natural calamities.

c) COVERED EXPENSES
LearnToLive will cover the following travel expenses: accommodations in guest houses and tents on double occupancy, three meals per day, service of guides, cooks, porters and drivers, all transfers to meet the group on arrival and departure date, all vehicle transfer while with LearnToLive in Indonesia.

d) EXPENSES NOT COVERED
LearnToLive will NOT cover the following expenses: domestic or international flights, connections at international airports, passports, visa, insurance , immunization, medical costs related to illness or injury, evacuation from remote areas, alcoholic beverages, laundry, excess charges, pick-up & drop-off at port of arrival/departure on trip dates, expenses arising from delay or extension of a trip due to weather, landslide, illness, failure of transportation, cancellation of flights or causes beyond the control of LearnToLive staff.

e) PARTICIPANTS RESPONSIBILITY
As a participant on any of our Health Expeditions you have responsibilities to yourself and other team members accompanying the team and people of the areas you travel to.  These responsibilities include:
* Selecting a trip appropriate to your physical ability
* Bringing proper equipment and clothing as advised in the Pre-Travel Advice document.
* Reading and understanding the information provided by LearnToLive
* Following the directions of your trip leader
* Behaving in a manner respectable towards natural environments and local customs of the areas you visit or travel to.
Please re-type your name *
By typing your name you acknowledge, understand and accept these terms and conditions.
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report