UGAB form

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Terms

Participant's details First Name: Last Name: Gender: Date of Birth: Place of Birth: Citizenship: Height: Weight: Size (T-Shirt): Photo:

Contacts Phone: Email: Country: State: City: Zip/Postal: Address:

Father Father’s Name: Phone: Email:

Mother Mother’s Name: Phone: Email:

Emergency Contact Name: Relation: Phone: Email:

Knowledge of languages English: French: Armenian:

Has the participant been to Armenia before? Been to Armenia: Date and the reason for the visit:

Does the participant have relatives in Armenia? Relatives in Armenia: Name of relative: Relation: Phone: Email:

Person to notify in case of an emergency Name: Relationship: Phone: Email:

Address Country: State: City: Zip/Postal: Address:

Physician’s Contact Information Name: Country: State: City: Zip/Postal: Address: Phone: Fax:

Medical Insurance Insurance Company: Policy Number: Subscriber: Signature: Card photocopy (?):

Medical Treatment

Medications

Allergies

Restricitions

This form is required ONLY if you responded positive to any of the questions in the previous step.

Physician’s Report

PARTICIPANT CODE OF CONDUCT AND AGREEMENT FORM

Please carefully review the following rules and regulations of the Program. This agreement must be signed by the participant as well as his/her parent or legal guardian.

Participants must always follow the directions of the Program Director and Staff.
Participants must respect the environment by not littering.
Participants must treat house equipment and property with care.
Participants must stay with their group and the Program Staff at all times and may not leave the group unaccompanied without the express consent of the Program Director.
Under NO circumstances can participants host overnight guests or spend the night elsewhere, regardless of their relation. Participants who break this rule will be subject to dismissal from the Program.
Alcohol, tobacco and drug use of any kind are strictly prohibited throughout the Program. Participants who break this rule will be subject to immediate dismissal from the Program.
Participants should not make any summer plans that will conflict with their participation in AGBU Discover Armenia and must commit to the full duration of the Program, except in the case of an unforeseen emergency, of which they must notify the AGBU Discover Armenia Director immediately.
Visits during the Program are disruptive to the schedule and those not directly involved with the Program will not be permitted to accompany participants on their trips or community service activities. Although we understand that parents, friends or relatives might want to join the participants in Armenia, we ask that all joint travel plans be made either prior to or following the Program in efforts to preserve the flow and integrity of the Program for the staff and the other participants.

I, have read the AGBU Discover Armenia rules and regulations listed above and agree to abide by them throughout the duration of the program. I understand that these rules and guidelines are for the safety and the protection of the participants and staff of the Program. I further understand that if I choose to violate the rules and regulations set forth by AGBU Discover Armenia or engage in conduct that endangers the safety of my fellow participants, the Program director will take appropriate steps to stop my actions or behavior. These steps may include a verbal warning, parent notification and/or dismissal from the Program.

In the event that I am dismissed from the program due to a breach of regulations on my part, I understand that no full or partial reimbursement of the 1000€ Participation Fee will be granted to me by the AGBU Discover Armenia Program and that I will not hold AGBU responsible for any additional expenses (e.g. additional travel arrangements, etc.) that may occur as a result of my early dismissal from the Program.

I hereby release AGBU, its agents and employees from all liability, damages, causes of action, and the like during my participation in the AGBU Discover Armenia Program.

CANCELLATION POLICY

In the event that a participant wishes to withdraw from the AGBU Discover Armenia Program for any reason, he/she must inform the Program Director in writing immediately.

Cancellations prior to June 1, 2022 are subject to a non-refundable fee of 500€.

No refunds will be granted for cancellations made after June 1, 2022.

AUTHORIZATION STATEMENT

I hereby authorize AGBU Discover Armenia to release information from my medical history, including but not limited to medical records, to the relevant Program Director and to the cooperating or affiliated foreign institutions.

I understand that AGBU Discover Armenia will not request any information from my medical records unless a situation arises while I am abroad that requires information pertinent to my safety or health. I further understand that any information obtained from of my medical records that is held by the AGBU Discover Armenia will be destroyed upon the completion of my participation in the program.

I understand that, if I have a medical condition that requires or has required treatment, I must discuss my plan to go abroad with my clinician prior to my departure.

I understand that in the event that I need emergency medical care, hospitalization or surgery while participating in the program, AGBU will attempt to contact the emergency contact(s) listed on this form. In the case that my emergency contact(s) cannot be reached and an immediate decision about care or treatment needs to be made, I authorize AGBU Discover Armenia, through its representatives, to secure any necessary treatment. If coverage is not provided through my insurance program, I understand that such treatment shall be solely at my expense. I release, discharge, indemnify, covenant not so sue, and agree to hold harmless AGBU, it members, officers, agents and employees, from any liability which may result from authorizing any medical treatment and/or medication for me. I certify that all responses on this Medical Assessment and Release Form are true and accurate.

I certify that the information on this Medical Information Form is true and correct, and I will notify the AGBU Discover Armenia program hereafter of any significant or relevant changes in my health that occur prior to or during the program.

For Participants under 18:

I understand while participating in this program, my child may be photographed or filmed by members of AGBU (UGAB) staff and their assigns. I agree to allow his/her photo, video, or film likeness to be used for any legitimate purpose by AGBU for marketing materials, included but not limited to, web publications, brochures, magazines, advertisements, social media or any other media that exists now or in the future, in each case without his/her name. AGBU shall have the exclusive right to any such media and other reproductions thereof and copyright therein.

I, , have reviewed these rules with my child/minor and agree to the terms and conditions.

Signature identified by IP Address: 44.212.94.18 on Date: 08/12/2023 07:23:25.