Vacation with a Purpose Kenya

Dates: October 13-26, 2024

Team type: Open team (nurses and midwives)
Cost of event: $2500 plus airfare
Team Capacity: 5
Last day for full payment: 45 days before the trip

Sign up now to participate in 'Vacation with a Purpose Kenya' using the form below. You'll be interviewed by the team leader prior to being accepted in the team. After being accepted, you will then need to pay the non-refundable deposit of $300 to confirm your place on the team - however this is only after being accepted for the team.

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PERSONAL INFORMATION:
First Name *
Middle Name
Last Name *
Preferred Name *
Mailing address *
City *
State / Province *
Zip / Postal Code *
Country *
Home Phone *
Cell Phone *
Email address *
   (email is the preferred method of communication)  
Citizenship *
Date of Birth *
MM
/
DD
/
YYYY
Gender *
Occupation *
If student, school name
Traveling with a companion or group? 
 *
(Each person must fill out their own application)  
Group Name
Companion name
Companion relationship
PASSPORT INFORMATION:  
Passport Number  
Expiration Date
MM
/
DD
/
YYYY
Place of Issue
ADDITIONAL INFORMATION:
Why are you interested in participating in this event?  
 *
Previous volunteer experience (please describe, including where and when):
*
Previous international travel experience (please list countries and length of stay):
*
Please list any special skills (first aid, photography, writing, construction, etc):
*
LANGUAGES (Other than English):
Fluent  
Conversational
Beginner
HEALTH:
Physical fitness:  
 *
Medications you currently take:   
 *
Special Dietary requirements:
*
Allergies, physical limitations, handicaps, etc.
*
Emergency Contact Information
In case of emergency, please contact:  
Name
 *
Relationship
 *
Full Address
 *
Day phone
*
Night phone
*
Personal physician information:
Name *
Full Address *
Day phone  
Night phone  
Personal health insurance information:
NOTE: You are responsible for procuring your own travel medical insurance, including emergency evacuation insurance.  
Company  
Policy number  
Insurance agent
Agent phone
  Coverage includes emergency evacuation?  
Clear selection
Event Waivers
You agree to AFCA's payment policies which can be found here: https://www.afcaids.org/wp-content/uploads/2023/02/VWP-payment-policies-and-procedures-2023.pdf
 *

After completion of this registration form, you will also need to download the following two forms

- Participant acknowledgement form (https://www.afcaids.org/wp-content/uploads/2022/10/VWP-Participant-Acknowl.pdf)
- Release and Waiver form (http://www.afcaids.org/wp-content/uploads/2018/07/vwp-release-waiver-form.pdf)

These forms need to be completed and signed and then sent to AFCA. They can either scanned and emailed to Tifany Jimenez Burgos at tijibu96@gmail.com or mailed to:

American Foundation for Children with AIDS
1520 Greening Lane
Harrisburg, PA 17110
USA

You agree to complete these two forms and send to AFCA:

 *
Yes
No
Participant acknowledgement form
Release and Waiver form
Submit
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