Service Trip/Immersion Programs Application Form

The Service Trip/Immersion Program Application Form provides transparency and ensures understanding between program leaders/organizers and participants regarding program goals and learning outcomes, participant expectations, participation costs and requirements, and personal safety risks associated with the program. This form should be included in all participant application materials. These forms should be used in the following way:

To Prospective trip participants: The following information is provided by the Service Trip Organizer to help you make an informed decision before applying or committing to a service trip. You are encouraged to consider this information carefully and discuss it with your parents or guardians.

  1. Service Trip leaders/organizers will complete and distribute form to all applicants with applications.
  2. Prospective trip participants will initial beside each bullet to acknowledge understanding and agreement of all expectations and responsibilities when submitting their application.
  3. Service Trip leaders/organizers must submit completed, initialed forms along with a trip roster to the Gephardt Institute in DUC 150 before their program Service Trip Participant Training.
  4. Winter Trip Participant Training (11/6/16)
  5. Spring Trip Participant Training (2/12/17)
  6. Summer Trip Participant Training (4/9/17)
  7. NOTE: this process is required for any participants joininga program after the team has been selected.

By initialing beside each bullet, I acknowledge and agree to meet each of the requirements for this service trip.

Program Information

  • Service Trip/Immersion Program Name: ______.
  • Program mission and goals: ______.
  • Travel dates: Depart on______and returning on ______.
  • Travel details (please include details for all team travel. Plane layovers and personal travel to meet the group need not be included): Departing from ______to ______, then returning to ______. Other travel locations (if applicable): ______.
  • Describe lodging accommodations: ______.
  • Local transportation method and company: ______.

Financial Information

  • Program participation fee: ______, due by ______.
  • Late Cancelation Fee (total or percentage not refunded): ______.
  • Additional items that participants will need to acquire (supplies, travel documents, immunizations, etc.), and anticipated cost: ______.

Time Commitment

  • Pre-Trip Team Training Dates and times (At minimum, list quantity and duration): ______.
  • Participant Trip Training (Trip organizer, circle one training that applies):

Winter (Sun, Nov 14, 4:30-8pm)Spring (Sun, Feb 12, 1:30-5pm)Summer (Sun, Apr 9, 1:30-5pm)

  • Post-Trip Team Training Dates and times (At minimum, list quantity and duration): ______.

Health Risks and Safety Concerns

  • In 300 words or less, list all health and safety risks for all locations that you will travel, as determined by the U.S. Department of State’s travel registry, Centers for Disease Control, and International SOS. Denote locations if risks do not apply to all travel locations. Attach health and safety risks to this page.
  • NOTE: By initialing, participants assume the risks of this trip and acknowledge that there will be no Wash U faculty or staff participant to mitigate risk. Should an emergency occur during a trip, participants are encouraged to contact WUPD (314-935-3943) and Tim Dugan ().