Alternative Break Participant Application Thank you for your interest in applying to Maryland Hillel’s Alternative Break program! Learn more about this year’s trips and apply below. If you have any questions, email Rabbi Miriam. 1 Participant Info2 Health Survey3 Short Answers4 Waiver & Agreement Student InformationName* First Last Email Address* Cell Phone*What year do you expect to graduate from UMD?*2020202120222023Student Birthday*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920UID*Data SourceHow would you best describe your religious affiliation?*Jewish - Just JewishJewish - ReconstructionistJewish - ReformJewish - ConservativeJewish - OrthodoxAre you in a fraternity or sorority?*YesNoPlease select your Greek housePlease selectAlpha Epsilon PiAlpha Gamma RhoAlpha Chi OmegaAlpha Delta PiAlpha Epsilon PhiAlpha Kappa AlphaAlpha Nu OmegaAlpha Omicron PiAlpha PhiAlpha Phi AlphaAlpha Sigma PhiAlpha Tau OmegaAlpha Theta GammaBeta Theta PiChi Iota PiChi PhiDelta ChiDelta Delta DeltaDelta GammaDelta Phi EpsilonDelta Phi OmegaDelta Sigma PhiDelta Sigma ThetaIota Nu DeltaIota Phi ThetaKappa AlphaKappa Alpha PsiKappa Alpha ThetaKappa DeltaKappa Delta PhiKappa Phi GammaKappa Phi LambdaKappa SigmaLambda Chi AlphaLambda Theta AlphaLambda Upsilon LambdaOmega Psi PhiPhi Beta SigmaPhi Delta ThetaPhi Gamma DeltaPhi Kappa PsiPhi Kappa TauPhi Sigma SigmaPi Kappa AlphaSigma Beta RhoSigma ChiSigma Delta TauSigma Gamma RhoSigma KappaSigma NuSigma Phi EpsilonSigma PiSigma Psi ZetaTau Epsilon PhiTau Kappa EpsilonTheta ChiZeta Beta TauZeta Phi BetaZeta PsiZeta Tau AlphaHave you been on an Alternative Break program before?*YesNoWith what organization and to where did you go?Which program are you applying for?*GuatemalaParent 1 InformationParent 1 Name* First Last Parent 1 Email* Parent 1 Home Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Parent 1 Home Phone*Parent 1 Cell Phone*Parent 2 InformationParent 2 Name First Last Parent 2 Email Address Do your parents reside at the same home address?YesNoParent 2 Home Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Parent 2 Cell Phone Health SurveyThis confidential survey is to ensure your safety while on the trip. Please answer thoroughly and honestly.Insurance CarrierInsurance Policy NumberDo you have any allergies to food and/or dietary restrictions?*YesNoPlease explain.Do you have any hearing or vision problems?*YesNoPlease explain.Do you wear a medical alert bracelet or have a pre-existing medical condition that may require emergency treatment?*YesNoPlease 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?*YesNoPlease explain.Do you have any issues related to manual labor (stamina, asthma, coping with heat) or mobility?*YesNoPlease explain. Short AnswersWhat 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 AgreementPlease 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.CommentsThis field is for validation purposes and should be left unchanged.