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INSTRUCTIONS
UWO Dominican 2008
_________________________________________________________________________________
Dear Applicant,
Thank you for your interest in Hero Holiday® 2008. This trip is a private charter designed for University
of Western Ontario students. Your local contact person is Rossana Morales. She can be contacted via
email at rmorales@uwo.ca. The date for this trip is August 15 – 26, 2008.
Please read the instructions carefully and fill in all sections of the application form clearly, using blue
or black ink. You may mail the application and payments directly to our office or submit them to
Rossana Morales. Once we receive your registration along with a $250 deposit, a welcome letter will
be mailed to you.
REGISTRATION DEADLINE: JANUARY 15, 2008
Section 1 - Personal Information
Name. Please ensure the name you supply on this application form is the same name and spelling
that appears or will appear on your passport. If you have a preferred name which is different than the
name on your passport, please make note of this on the application in the space provided.
Passport Number. If you do not currently have a passport, you may leave this space blank and
inform us of the number as soon as you receive it. A passport is mandatory for participation in Hero
Holiday®. To obtain a passport, visit www.pptc.gc.ca to download an application or visit your local
passport office or post office. Please apply for your passport as soon as you know you are
participating in Hero Holiday® in case of a delay in obtaining your passport.
Mailing Address. Your welcome letter will be sent via mail. Please provide a full mailing address,
including postal code, to prevent delays.
Email. We communicate regularly to our participants via email. You must provide us with a valid email
address to ensure you receive important information updates.
Emergency Contact Information. Please provide us with the full name of the person you would like
us to contact in case of emergency during Hero Holiday®. Please make sure the numbers are correct
and the person is able to be contacted at any time at the numbers provided.
UWO/DR/2008
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Section 2 – Options
Team. You will have the choice of working on the medical team or the building team. The medical
team will be running medical clinics, facilitating health education classes for the local people and a
tour of a hospital. The building team will work on a building project which is yet to be determined.
Previous projects have involved the construction of a school, house or clinic. No previous experience
is necessary. Both teams will have an opportunity to visit an orphanage and a dump.
Roommate Requests. You may make up to three requests. Please make sure that each friend also
lists your name on their application form. We will do our best to accommodate requests, but we cannot
guarantee that all requests will be honoured. Four participants of the same gender will be allocated to
a room. If you would like to pay for a private room, the cost is $20 per night for a total of $200.
Section 3 - Medical Information
Medical Conditions. Please indicate all medical conditions by checking the boxes provided. Any
conditions marked with an asterisk require a doctor's written permission to participate in Hero Holiday®
and must accompany your application.
Medications. Please list all medications that require a prescription from a doctor and make sure the
spelling and dosage is correct. Medications must be stored in original containers.
Immunizations. It is recommended that you visit your family physician or travel clinic at least six
weeks before Hero Holiday® to ensure all immunizations are up to date. The immunizations listed on
the application form are current at time of editing and are subject to change. For more information on
immunizations, please visit the Public Health Agency of Canada at www.phac-aspc.gc.ca. Please
check off all vaccinations you have received. If you have not had the Varicella vaccine but you have
had chicken pox, you may check off that box. If your immunizations are incomplete, please sign the
waiver in this section.
Section 4 – Participant Agreement
Please read the Participant Agreement; sign and date it.
Section 5 - Payment Information
Trip Fees. The price for this trip is $2250. The $250 deposit is due with your registration by January
15, 2008. Your second payment of $1000 is due by April 8, 2008 and your final payment of $1000 is
due by July 8, 2008. Fees not paid in full by the deadline will be subject to a late payment surcharge of
1% per day. Please note that payment of fees by credit card are subject to a 3% surcharge. A
payment form and donation log (if applicable) must accompany your payment.
Trip fees include:
• Bus transportation from Hamilton to Buffalo
• Return flight from Buffalo to Santiago
• Bus transportation from Santiago to Sosua
• Accommodations and meals while in Sosua
• Daily transportation while in Dominican Republic
• All planned project expenses
UWO/DR/2008
-3Trip fees do not include:
• Travel costs to and from Hamilton from where you live
• Excursions during free time
• Personal spending money
• Passport expenses
• Vaccines
• Travel medical insurance
• Meals while traveling to and from Dominican Republic
Donations. Trip fees that are paid as a result of fundraising efforts are considered a donation and are
not eligible for refunds. Trip fees paid by the participant or an immediate family member are eligible for
a 50% tax receipt. All other donors can be issued a 100% tax receipt. Requests for such payments to
be logged as a donation must be made at the time of payment and those payments logged as a
donation are not eligible for refunds in the event of participant cancellation. Please include a payment
form and donation log (if applicable) with all payments.
Refund Policy. Please sign that you have read and have accepted the terms of the refund policy.
Important Note – Criminal Record Check
You must submit a Criminal Record Check including Vulnerable Sector Screening in order to
participate in Hero Holiday®. Visit your local police station to apply for a criminal record check. Each
police constituency is different and procedures vary. Many will give you a criminal check for free or at
a reduced rate as Hero Holiday® is considered volunteer work. Usually, your acceptance letter is
sufficient; however, some cities will require an additional form. You will be required to fax or mail the
form provided by the police station to our office for endorsement. You may send your criminal record
check separately from your application form. Original criminal record checks are required and must be
sent by mail. We cannot accept faxed copies. The criminal record check must not be more than six
months old.
If you need assistance in completing this application form, please contact us:
UWO/DR/2008
Phone
905-777-1662
Toll Free
1-866-531-HERO (4376)
Email
info@heroholiday.com
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UWO REGISTRATION
Dominican Republic August 2008
__________________________________________________________________________
SECTION 1 – Personal Information
Name (as it appears on your passport) _______________________________________________
Preferred Name (Optional ) ________________ Passport #
Mailing Address _____________________________________________________________
City _________________________ Province _____________ Postal Code _____________
Home Phone (
)____________ Cell (
)_____________
Gender M
O
F
O
Date of Birth _____________ Email Address _____________________________________
D
/ M
/ Y
What is your preferred method of communication? Phone
O
Email
O
If we need to contact you by phone, when is the best time? Days O Evenings O
What is your area of study?
O Nursing
O Medicine
O Dental
O Other________
Emergency Contact Information
Name ____________________________Relationship to Applicant_____________________
Home Phone (
)____________ Work (
)____________ Cell (
)_____________
Section 2 – Options
Which team would you like to be allocated to?
O Medical
O Building
I would like to be allocated to a room with the following people:
_______________________
_______________________
_______________________
O I am requesting a private room for the duration of Hero Holiday®. Please add a fee of $20
per night to my invoice. (Total $200)
UWO/DR/2008
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SECTION 3 – Medical Information
Medical Conditions: Please check all that apply. Those marked with an asterisk must be accompanied by a
®
doctor’s permission to participate in Hero Holiday .
O I HAVE NO MEDICAL CONDITIONS
O ADD/ADHD
O Headaches/Migraines
O Hypotension
O Back Injury
O Depression*
O Hypertension
O Hypoglycemia
O Arthritis
O Asthma
O Heart Disease*
O Hepatitis
O Motion Sickness
O Pregnancy*
O Tuberculosis*
O Hypothyroidism
O Hemophilia*
O IBS/Crohns
O Kidney Disease
O Diabetes
O Epilepsy*
O Other: ___________________________________
Please explain any limitations or required treatment of the above conditions:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Allergies. Please list all known allergies in the space provided. If you have a life-threatening allergy, it is
recommended you carry an Epi-Pen and wear a Medic-Alert bracelet.
O I HAVE NO ALLERGIES
Allergy
Symptoms
Are you currently taking any prescription medications?
Treatment
O Yes O No
Make sure you bring all necessary medications for the duration of the trip and have them stored in original containers.
If yes, list below:
Name of Drug
UWO/DR/2008
Dosage
Reason for taking
-3Required Immunizations: Please check all immunizations you have received.
O
O
O
O
O
O
TD (Tetanus/Diptheria)
MMR (Measels/Mumps/Rubella)
IPV (Polio)
Varicella (or history of Chicken Pox)
Hepatitis A
Hepatitis B
If your immunizations are not up to date, please sign the following waiver:
O
I recognize my immunizations are not up to date at this time. In the event that
immunizations are not up to date by the commencement of the trip, I release Absolute from
any lawsuit or liability claim that may come as a result of not being immunized.
Signature of Participant _____________________________ Date ____________________
SECTION 4 – Participant Agreement
1. I will attend all project activities.
2. I will not leave the project site or accommodations unaccompanied or without notifying a
team leader.
3. I will not display any non-participatory or anti-social behaviour.
4. I understand that the use of alcohol resulting in intoxication will not be tolerated. Alcohol
consumption will be limited to two drinks per day, and will not be consumed during the work
day.
5. I will not be found in possession of or use illegal drugs as doing so will result in immediate
dismissal from the program at my own expense.
6. I will not engage in any form of sexual misconduct.
7. I will display an attitude of respect to other participants and those placed in authority over
me.
8. I understand that not adhering to the above standards will result in losing the privilege of
participating in Hero Holiday® and I will be required to leave the program at my own risk and
expense.
9. I understand that throughout Hero Holiday®, photographs and video footage may be taken
of me during project activities. These videos/photos are property of Absolute and may be
used for promotional and/or educational purposes.
10. In the event of outstanding payments, Absolute reserves the right to cancel my
participation with no refund.
I have understood and agree to the conditions listed above.
Signature of Applicant _________________________________ Date __________________
UWO/DR/2008
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SECTION 5 – Payment Information
O Deposit
$ 250
Due with registration by January 15, 2008
Payment Options
O cheque or money order enclosed
O credit card
Please note that fees paid by credit card are subject to a 3% surcharge.
O Visa
O MasterCard
Name on card _________________________________ Amount $________________
Card Number _________________________________ Expiry Date _______________
Cardholder’s Signature _______________________________ Date _______________
Refund Policy
1. Donations are non-refundable. (Please refer to application instructions).
2. Application fees are non-refundable.
3. All requests for refund must be forwarded to Absolute in writing.
4. 80% of fees paid will be refunded until May 15, 2008.
5. 50% of fees paid will be refunded until July 1, 2008
6. After July 1, 2008 no refunds will be given except for extreme circumstances such as death
or severe illness/injury resulting in the individual being unable to participate. In such cases,
80% of trip fees will be refunded. Requests for refund must be accompanied by a copy of
death certificate or a doctor’s note.
7. Trip fees cannot be forwarded to the next Hero Holiday®.
I have read and agree to the above refund policy.
___________________________________________
Signature of Participant
___________________________
Date
Please mail to:
Absolute Leadership Development Inc.
Hero Holiday Application Processing Office
Box 25103 RPO West Kildonan
Winnipeg MB R2V 4C7
UWO/DR/2008
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PAYMENT FORM
Participant’s Name _______________________________
Is this payment a result of a fundraiser?
YES
Is this payment a donation requiring a tax receipt?
NO
YES
If yes, is this donation from a participant, parent or sibling?
O Donation log included
Project: UWO 2008
O Donation log to follow
NO
YES
NO
O This is not a donation
...........................................................................................................
PAYMENT FORM
Participant’s Name _______________________________
Is this payment a result of a fundraiser?
YES
Is this payment a donation requiring a tax receipt?
NO
YES
If yes, is this donation from a participant, parent or sibling?
O Donation log included
UWO/DR/2008
O Donation log to follow
Project: UWO 2008
NO
YES
NO
O This is not a donation
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DONATION LOG – HERO HOLIDAY® 2008
Participant Name ___________________________________________________________
Donor Name _______________________________________________________________
Donor Address _____________________________________________________________
Street
_________________________________________________________________________
City
Province
Postal Code
Donor Phone Number (_______)_________________________________
Amount Donated $____________________________________________
Please read the following:
Absolute Leadership Development Inc. requires that each donor wishing to be issued a tax
receipt fill out this form. It is the responsibility of the Hero Holiday participant to ensure these
donation logs are forwarded to our office in a timely manner. In order for a tax receipt to be
issued in February 2008, the donation and the donation log must be received in our office no
later than December 31, 2007. All donations received after December 31, 2007 will be issued
a tax receipt in February 2009. For the participant and immediate family members, i.e.
parents and/or siblings, a receipt will be issued for 50% of the total amount donated. All other
donations to the Hero Holiday project will be given a tax receipt for 100% of the total amount
donated. Donations are non-refundable in the event of participant cancellation. In this case,
funds will be allocated to the current Hero Holiday project. Tax receipts will be issued for
donations of $10 or more. Please note that a tax receipt can only be issued in single name or
business name.
________________________________________
Signature of Donor
________________________________________
Signature of Hero Holiday® Participant
Please mail to:
Absolute Leadership Development Inc.
Hero Holiday Application Processing Office
Box 25103 RPO West Kildonan
Winnipeg MB R2V 4C7
UWO/DR/2008