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Alternative Break Trip
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Students
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Alternative Break Trip
Alternative Break Participant Application
1
Participant Info
2
Health Survey
3
Short Answers
4
Waiver & Agreement
Student Information
Name
*
First
Last
Email Address
*
Cell Phone
*
What year do you expect to graduate from UMD?
*
2024
2025
2026
2027
2028
Student Birthday
*
Month
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UID
*
Hidden
Data Source
How would you best describe your religious affiliation?
*
Jewish - Just Jewish
Jewish - Reconstructionist
Jewish - Reform
Jewish - Conservative
Jewish - Orthodox
Are you in a fraternity or sorority?
*
Yes
No
Please select your Greek house
Please select
Alpha Epsilon Pi
Alpha Gamma Rho
Alpha Chi Omega
Alpha Delta Pi
Alpha Epsilon Phi
Alpha Kappa Alpha
Alpha Nu Omega
Alpha Omicron Pi
Alpha Phi
Alpha Phi Alpha
Alpha Sigma Phi
Alpha Tau Omega
Alpha Theta Gamma
Beta Theta Pi
Chi Iota Pi
Chi Phi
Delta Chi
Delta Delta Delta
Delta Gamma
Delta Phi Epsilon
Delta Phi Omega
Delta Sigma Phi
Delta Sigma Theta
Iota Nu Delta
Iota Phi Theta
Kappa Alpha
Kappa Alpha Psi
Kappa Alpha Theta
Kappa Delta
Kappa Delta Phi
Kappa Phi Gamma
Kappa Phi Lambda
Kappa Sigma
Lambda Chi Alpha
Lambda Theta Alpha
Lambda Upsilon Lambda
Omega Psi Phi
Phi Beta Sigma
Phi Delta Theta
Phi Gamma Delta
Phi Kappa Psi
Phi Kappa Tau
Phi Sigma Sigma
Pi Kappa Alpha
Sigma Beta Rho
Sigma Chi
Sigma Delta Tau
Sigma Gamma Rho
Sigma Kappa
Sigma Nu
Sigma Phi Epsilon
Sigma Pi
Sigma Psi Zeta
Tau Epsilon Phi
Tau Kappa Epsilon
Theta Chi
Zeta Beta Tau
Zeta Phi Beta
Zeta Psi
Zeta Tau Alpha
Parent 1 Information
Parent 1 Name
*
First
Last
Parent 1 Email
*
Parent 1 Home Address
*
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Parent 1 Home Phone
*
Parent 1 Cell Phone
*
Parent 2 Information
Parent 2 Name
First
Last
Parent 2 Email Address
Do your parents reside at the same home address?
Yes
No
Parent 2 Home Address
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Parent 2 Cell Phone
Health Survey
This confidential survey is to ensure your safety while on the trip. Please answer thoroughly and honestly.
Insurance Carrier
Insurance Policy Number
Do you have any allergies to food and/or dietary restrictions?
*
Yes
No
Please explain.
Do you have any hearing or vision problems?
*
Yes
No
Please explain.
Do you wear a medical alert bracelet or have a pre-existing medical condition that may require emergency treatment?
*
Yes
No
Please explain the nature of the condition and what medical treatment might be necessary.
Are you currently suffering or do you have a history of mental health, social, or behavioral illness or disorders?
*
Yes
No
Please explain.
Do you have any issues related to manual labor (stamina, asthma, coping with heat) or mobility?
*
Yes
No
Please explain.
Short Answers
What are you hoping to gain from an Alternative Break experience? What could you contribute as a participant, both during the program and upon your return?
*
This program involves communal living, working, and learning. Describe two things you like about working with a group and two things you find frustrating.*
*
Waiver and Agreement
Please review the waiver which details the Maryland Hillel policies on liability, medical liability, conduct during an Alternative Break trip, and a photography release.
Liability
You hereby acknowledge that Maryland Hillel, its Boards of Directors, officers, servants, agents, employees, and representatives, and all individuals and organizations that provide financial support directly or indirectly to Maryland Hillel shall not be liable or responsible for any loss or damage which you may sustain to your person or property. It is understood and agreed that Maryland Hillel assumes no responsibility whatsoever, and shall not be held responsible for the operation and management of any of the facilities which may be employed in connection with the Maryland Hillel Alternative Break (AB) program for any damage or claim arising there from or in connection therewith.
Medical Liability
I have consulted a physician of my own choice and have been advised by said physician that I am in good health, do not suffer from any physical or mental ailment or disability, which would make my travel and/or participation on an AB hazardous, unwise, unwarranted, or a potential source of danger to me or to others who may travel with me or participate on the Maryland Hillel AB. I acknowledge that AB activities, including, but not limited to, work that requires physical labor, bus and van travel, work within different neighborhoods of a city, may be subject to certain hazards; and further that I am voluntarily participating in an AB and these activities, and understand the dangers and risks involved. Use of power tools are subject to approval by staff. I understand that these activities are potentially dangerous and could result in permanent injury or death. I understand that due to the area and season in which I am traveling to may cause plans to change at the last minute. I hereby agree to accept any and all risks associated with participating in an AB. As with any traveling and/or volunteer activity, there are certain inherent risks. Should I require emergency medical treatment as a result of illness or accident arising during the AB, I consent to such treatment. I agree to inform Maryland Hillel of any medical conditions (e.g. allergies, asthma, epilepsy, bee sting reactions, etc.) I have of which I am aware that may limit the extent of my physical abilities/participation and about which emergency personnel should be informed. Further, I agree to reimburse Maryland Hillel for any and all costs associated with the provision of medical care and treatment to me during the trip, including monitoring fees provided by external providers, whether I consented to medical treatment myself or whether a Maryland Hillel staff consented on my behalf. I understand that Maryland Hillel will not accept reimbursement of any medical expenses through my carrier, but that I must personally reimburse Maryland Hillel within a month of the trip. This release is intended to be broad in its effect. I hereby agree to accept and assume any and all risks of injury, illness, or death, and verify this statement by providing my electronic signature. In consideration of being permitted to participate in the AB program offered by Maryland Hillel, I voluntarily agree to indemnify, release, and hold harmless the State of Maryland, the University, and Hillel and their respective officers, agents, employees, and volunteers from any and all costs, liabilities, expenses, claims, compensation, demands, causes of action on account of any loss or personal injury to me that might result from participation in the AB, whether arising through my own negligence, omission, default or that of the university. I am aware of all of my personal medical needs, and have arranged for adequate hospitalization insurance to meet any and all needs for payment of hospital costs while participating in the AB. I understand and agree that: Maryland Hillel does not have medical personnel available at the location(s) of the AB program, during transportation, or anywhere else in any location to which I may travel while participating in the AB program. I am not relying on the University of Maryland, or any university official or employee for my medical needs. I understand and agree that the university is not responsible for attending to any of my medical or medication needs, and I assume all risk and responsibility. Therefore, if I am required to be hospitalized while participating in this program, the university does not assume any legal responsibility for payment of any costs associated with such hospitalization. Notwithstanding the above, in any emergency situation, I authorize the AB program director solely at his or her discretion, to procure all necessary medical assistance and to authorize any competent medical person to do all things reasonably necessary to treat any injury or illness which occurs during my participation in the program. I agree that neither the university, Maryland Hillel, nor the AB program director is required to provide for or obtain any medical treatment for me. I have a medical insurance policy which covers me during my participation in this program.
Conduct and Termination
I agree to abide by all rules, requirements, policies and guidelines of Maryland Hillel, the university, any outside program provider, and any other organization or entity that is conducting activities or providing goods or services in connection with the program. In particular, I acknowledge that AB programs are completely drug and alcohol free, and I will not use alcohol or illegal drugs during the program. I further agree to abide by the laws of the local country and community and to behave in a manner that is appropriate in the local community and reflects well on the university. If I violate any of these laws, rules, requirements, policies, guidelines, or standards of conduct or otherwise behave in a manner that is considered by Maryland Hillel or the university to be detrimental to myself, other participants, the program and/or the university, Maryland Hillel shall have the right to limit or terminate my participation in the program. If my participation is limited or terminated, there will be no refund of any fees and I will be responsible for all expenses incurred as a result of my termination, including the costs of my return home. Furthermore, I agree to pay for any property that has been lost or has incurred damage during the trip because of misuse, including damage to housing accommodations, rental cars, or equipment of on-the-ground service partners.
Photography Release
I hereby give Maryland Hillel permission to post or publish my name and quotes, articles, thank-you letters, or photographs related to my participation in the AB, in whole or in part, without compensation, on any pages of the Maryland Hillel website, which is currently located at marylandhillel.org, and on any pages of a supporter’s website and in any promotional materials prepared for or on behalf of Maryland Hillel. I give permission to Maryland Hillel to photograph, film, and videotape me and to use those images in support of purposes and programs. I understand that this permission authorizes Maryland Hillel to reproduce, display, and distribute my image in print, online, or by other means using any medium and technology now known or hereafter developed. I expressly waive any right or privilege to inspect these images in advance and/or to claim compensation of any kind for their use. I also expressly waive any and all rights of privacy and any and all rights accruing under the federal Family Educational Rights and Privacy Act and applicable Maryland law that I may have. I forever discharge and release Maryland Hillel and the University of Maryland and its employees, officers, agents, and students from all claims and causes of action, including but not limited to claims for invasion of privacy or misappropriation, liabilities and damages arising out of the authorized use of my images. I acknowledge that I have carefully read this photographic release and fully understand its contents. I understand and agree that this release is intended to be as broad and inclusive as permitted by the laws of the State of Maryland, that this release shall be governed by and interpreted in accordance with the laws of the State of Maryland, and that any suit arising out of my involvement in activities of the Maryland Hillel AB program be brought in the courts of the State of Maryland. I agree that in the event that any clause, sentence, or provision of this release is held invalid by any court of competent jurisdiction, the invalidity of such clause or provision shall not otherwise affect the remaining provisions herein which shall continue to be enforceable.
Electronic Signature
*
First
Last
By signing you are verifying your understanding of, and your agreement to, the terms of Maryland Hillel’s policies during the entire length of the trip. You acknowledge that you have voluntarily applied to the Maryland Hillel Alternative Break program to participate in volunteer activities at locations in or around the program location.
Name
This field is for validation purposes and should be left unchanged.
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