Witness for Peace Travel Program Application Print this form, fill it out completely and send it to Witness for Peace as indicated at the bottom of the application. Please write, type or print the answers to “Experience and values” questions on a separate page. Number your responses ac-cording to their corresponding questions. Please keep them brief. If you have any questions, please call 202-547-6112.
BASIC BACKGROUND INFORMATION:
Name (First, Middle, Last)
Current Mailing Address
City, State Zip
City, State Zip
Phone : ___________________ Day _________________Evening Email:
Destination of delegation: _______________________________________________ Date of delegation (mm/dd/yy): ____/____/____—____/____/____
Contact me by: Phone____ Email_____ No Preference_____
Date of Birth Female Male
Passport # Birthplace
(City, Country) Exp. (mm/dd/yy)
How did you hear about this Advertisement Mailing Event Testimonial Search engine delegation? From a friend (name) ________________ Other _____________________ HEALTH AND EMERGENCY INFORMATION:
Negative answers to the following questions will not necessarily prevent you from being invited to travel with WFP. This information will help us in assessing your special needs and allow us to take measures which would reduce the risks of
serious health matters during the course of the trip. Providing false information will result in dismissal from the program and Witness for Peace is not responsible for health issues that may occur during the course of the trip. General Health Excellent Good Fair Poor
(e.g., vegetarian -- Please note that while there will usually be vegetarian options, vegan options are very
difficult. Flexibility is necessary as it may be difficult to accommodate rigid dietary needs in areas where Dietary Concerns foods are difficult to get and local customs differ.)
Do you have any physical weaknesses, allergies, disabilities, illnesses that would impact your mobili-ty on this delegation? No Yes (Please explain)
Do you have any history of drug and/or alcohol abuse? No Yes (Please explain)
Are you currently under a physician's care or receiving prescribed medication of any kind? No Yes (Please explain)
Have you been hospitalized for an emotional or mental illness in the last two years? If so, are you
currently under a physician's care or receiving prescribed medication for this condition? No Yes (Please explain)
Whom should we contact in case of emergency? (Please make sure that the person knows to call
the WFP office in Washington, DC if it is urgent that they get in touch with you.)
City, State, Zip
Phone _________________(day) ________________(eve) Email: _______________________
LANGUAGE SKILLS AND REFERENCES:
Spanish Fluent Good Fair Poor
Other Language Fluent Good Fair Minimal
Please provide two personal references:
Name #1 Friend Co-worker Clergy Years Known Address
City, State, ZIP Phone
Name #2 Friend Co-worker Clergy Years Known Address
City, State, ZIP Phone
EXPERIENCE AND VALUES
Please write, type or print the answers to the following questions on a separate page. Number res-ponses according to their corresponding questions. Please keep answers brief (up to 150 words). #1: Briefly describe your experience with human rights, social justice, environmental, or other organ-izations that are committed to social change?
#2: Have you ever traveled to Latin America or the Caribbean? No Yes
Please briefly describe your experience.
#3: How did you hear about Witness for Peace and why would you like to participate in the WFP
#4: Why do you want to travel with this particular delegation?
#5: What is your position on non-violence?
If you are a member of a faith group, please list your faith and place of worship. (Optional—This data is used to help WfP fundraise from certain progressive religious foundations.)
Application for the Witness for Peace Travel Programs requires a $150 deposit. (This non-refundable deposit is applied to the total fee.) Any delegation application submitted by email or online from our website must be
accompanied by credit card payment information for the deposit. Please provide credit card information be-low, or see our mailing address for payment by check below. (Note: Because Witness for Peace has to pay
a finance charge to credit card companies, we would appreciate payment of fee balances by check, or a do-nation of an additional 3% from those wishing to charge fee balances to credit cards.)
Check Money Order Credit Card (include information below) Payment
Visa Mastercard American Express Discover Credit Card Information:
Name (as appears on card)
City, State, ZIP
Card # 3-digit security code (from back of card):
I authorize Witness for Peace to charge $150.00 to the credit card specified above, as a deposit to-ward participation in this delegation.
Once completed, please sign and date your application below, thus assuring us that the information contained in it is truthful and accurate.
________________________________________________ _________________________ Signature Date
Then, please email the form to email@example.com, and print out and place a signed original in the mail to us at the address below. (If you do not have access to email, the signed original in the mail will be sufficient in itself.)
Please MAIL this completed form with check, money order, or cc info to: thWitness for Peace—3628 12 Street, NE—Washington DC 20017
We are pleased that you are interested in one of our delegations.
A Witness for Peace representative will contact you once your application has been reviewed.
CANCELLATIONS AND REFUND POLICY
International travel can be drastically affected by unforeseen circumstances. Due to the extensive preparations and expenses that Witness for Peace incurs on behalf of delegation programs, we follow the following cancella-tions and refund policy guidelines.
*All delegate cancellations and refund requests must be submitted in writing to:
National Delegations Organizer
Witness for Peace thst3628 12 Street, NE, 1 Floor
Washington, DC 20017
One Month Prior to Delegation Departure
Refund requests received up to 1 month before delegation departure will be issued a full refund minus the $150 deposit.
30 Days or Less until Delegation Departure Date
Delegation Credit: Refund requests received with less than 1 month of departure are eligible for a delegation credit of the entire delegation fee amount less any non-refundable expenses already incurred by Witness for Peace, such as domestic airline tickets or lodging. This delegation credit amount can be applied toward a future WFP delegation of your choice. This credit will be issued in the form of a written letter with the requisite ac-counting information from the WFP National Delegations Organizer.
Cash Refunds: For delegates wishing to receive a cash refund, any refund request received less than 1 month before the departure of the delegation is eligible for a 50% cash refund of the full delegation fee, less the $150 deposit, $50 processing fee and any non-refundable expenses already incurred by Witness for Peace, such as domestic airline tickets or lodging.
Witness for Peace cannot offer a refund to delegates that do not arrive or depart on the scheduled dates due to changes or cancellations made by airlines or other transportation companies. We encourage delegates to seek appropriate refunds directly from transportation company representatives.
Due to the sensitive nature of Witness for Peace delegations, itineraries are subject to change. If there is domes-tic air travel, Witness for Peace will refund to delegates any funds it is able to recover whenever possible, if the itinerary is changed due to security or other safety concerns.
Delegates may wish to consider purchasing additional travel insurance before their trip. One provider is Trave-lex Insurance, which provides insurance that covers trip cancellation, medical expenses, and travel assistance. Basic travel insurance coverage for most delegates will range between $50-$100. For more information on benefits and rates, visit www.travelex-insurance.com.