Application Form

Application Form

Medicinal Plants and Cultures of the Amazon

July 7-21, 2018

Please complete all appropriate sections and e-mail to:

Global Awareness Institute (GAI): gai.global@yahoo.com

AND

Provide a hard copy to your home institution

 

A    GENERAL  INFORMATION

Name (as on passport):

                                                      First                             Middle                              Last

Passport Number:                                              Expiration Date:

 

Date of Birth:                                                      Gender:   Male   Female

                                 Month/Day/Year

Citizenship:

                                   Country

Local Address:

                                   Street                                                               Apt/Box No.

                            

                                  City                                                                  State           Zip

 

Address Valid From:                 to

 

Tel. No.:                                                        E-mail:

 

Permanent Address:

                                   Street                                                                Apt/Box No.

                                

                                  City                                                                   State              Zip

 Tel. No.:                                                      E-mail:

 

B      ACADEMIC HISTORY AT INSTITUTION

Name of Current College/University:  ______________________________________

Current Standing:       Fresh     Soph     Jr     Sr     Grad     Pharm P-2     P-3     P-4

(Must have completed P-2 year to go on the rotation, unless prior permission is granted)

Current GPA (Good Academic Standing Required):

Circle One:  Pharmacy Rotation or Pharmacy Elective Credit

Credit hours granted by home institution ____

(Applicants are responsible for purchasing Travel/Trip Interruption insurance; no refunds are given for any reason after April 15)

C       MEDICAL HISTORY

How would you describe your general health?

 

How would you describe your overall physical condition? (Include regular exercise programs, if any)

 

Please list ALL medications you have taken during the past two years.

 

Are you presently taking any medications? Please list.

 

Are you allergic to any medications? If so, please list.

 

Do you have any other allergies (include insects)? Please list.

 

Do you have any condition that could preclude you from exposure to or from participating in rigorous

physical activities, poor quality food or drinking water, or circumstances of travel via plane, canoe or

local transport, none or poor medical facilities, endemic diseases (malaria, yellow fever)?  Please list.

 

 

Name of your physician:

 

Address of your physician:                                                                     Phone:

 

Your physician must complete the medical history form we will provide to you as a condition of your acceptance to this program.

 

D      STUDY ABROAD FINANCIAL OBLIGATION

AMAZON PROGRAM

Program cost: The cost of the program from Lima, Peru is $3,150.  Included are round trip airfare Lima-Iquitos, lodging and meals at GAI’s jungle lodge near Iquitos, tuition for classes in Peru, and all scheduled field trips.   Not included are personal items and meals while away from the reserve.

Financial Aid: Financial aid and scholarships are the responsibility of student participants.  Students should consult the Office of Financial Aid at their home institution for complete information on eligibility requirements and application deadlines.  You may be eligible for study abroad funds.

Application fee: There is no application fee for this program; however, a deposit of $500.00 must be received by GAI before your application can be considered. Other payments must be received according to the following schedule.  Late payments may disqualify you from the program.

Payment schedule checklist and document due dates:

January 15
_____Amazon program application (an electronic copy of application must be sent to: gai.global@yahoo.com) and $500.00 deposit due. Students who are unable to go on the trip will receive 1/2 of the $500.00 deposit back if they notify GAI before it purchases airline tickets.

_____Passport numbers to: gai.global@yahoo.com (This is a deadline date to assure airline seats on group flights (we cannot guarantee group seating without a passport number)

February 15
_____ $1,000.00 due for Amazon program.  $750 refundable before April 15, minus pre-pays.

_____ Physician’s Verification Form to:    Global Awareness Institute (GAI)
P.O. Box 920
Fort Lauderdale, FL 33302

April 15
_____ $1,650.00 due for Amazon program. There will be no refund beyond April 15 for any reason, including illness.

_____ Release Of Liability And Assumption Of Risks Form to: Global Awareness Institute (GAI)
P.O. Box 920
Fort Lauderdale, FL 33302

Note:  GAI turned the optional Cuzco/Machu Picchu tour over to an independent tour conductor in 2013.  Please indicate your interest in that option below.

___ I am interested in receiving information about the optional Cuzco/Machu Picchu tour, July 21-28, 2018.

E    SELF EVALUATION

Language Skills: Please indicate whether your speaking and comprehension proficiency level is elementary (E), intermediate (I), fluent (F), or no proficiency (N)

Spanish:

Other:

How would you rate yourself on the following? EXPLAIN each of your answers in a short narrative response. 1= outstanding, 2= average, 3= needs work, 4= poor, 5= unable to evaluate

  1. Listening, comprehension, and retention skills?      1    2       3       4       5

Explain:

 

  1. Communication skills in small and large groups of people you know?       1       2       3       4       5
  2. Communication skills in groups of people you don’t know?                        1       2       3       4       5

Explain:

 

4. Independent thinking skills?      1      2      3      4       5

Explain:

 

5. Ability to work well in groups

a) Under normal conditions?       1      2      3      4       5

b) Under stressful conditions?     1      2      3      4       5

Explain:

 

6. Leadership skills?      1     2      3      4     5

Explain:

 

7. Ability to withstand extreme physical & emotional challenges?      1      2      3        4     5

(e.g. uncomfortable living conditions, strenuous walking & rowing, bugs, heat, dirt; minimal free time, total immersion in a foreign language and culture)

Explain:

 

8. Camping skills?   1     2      3        4     5

Explain:

 

9. Is there anything else we should know about you to better enable us to assess and serve your needs? Explain:

 

III.   Please answer the following questions with a short narrative:

1. How do you think that your participation in this program will benefit the rainforest and its inhabitants?

 

 

 

2. How do you think that this program is going to enhance your character and your profession?

 

 

 

F      TRAVEL HISTORY

Have you traveled outside the United States before?  Please list all countries visited and what you did there. What was the purpose of your trip?  Who did you travel with?  Did your travel include service to others?

 

 

 

Note to Foreign Students:

Foreign students should check with the appropriate officials at their home institution regarding mechanisms for retaining the student visa while enrolled in this program.

     APPLICATION DEADLINES

The application deadline for the Amazon program is January 15, 2018.

There is a minimum 15 student requirement for a group.

H   VALIDATING SIGNATURE BY APPLICANT

I certify that the information given on this form is correct to the best of my knowledge. I agree to sign appropriate release forms before embarking on study abroad.

 

Signature: ________________________________________________________

Date:

Provide an electronic copy of your application to: gai.global@yahoo.com  and a hard copy of this signature page, with deposit, to:

Global Awareness Institute or GAI

P.O. Box 920

Fort Lauderdale, FL 33302

Remember, send application to: gai.global@yahoo.com