Team Leader & Team Member Application

VOCATIONAL TRAINING TEAM

TEAM LEADER & TEAM MEMBER APPLICATION

PERSONAL INFORMATION

Team leader  Team member 

Family name: First name:

Preferred name:

Rotarian:  Yes  No

Gender:  Male  Female

Date of birth (must be at least 18):

If you are married, is your spouse applying?  Yes  No

f yes, provide spouse’s name for housing assignment:

Address:

Number and Street

City State/Province Country Postal Code

Email:

EMERGENCY CONTACT INFORMATION

Family name: First name:

Relationship:

Address:

Number and Street

City State/Province Country Postal Code

Email:

REFERENCES

Please provide two references with this application. Give one form to your employer and one to a friend, and submit the completed forms with this application.

PROFESSIONAL EXPERIENCE

You must provide an electronic copy of your curriculum vitae or résumé, copy of current license, and appropriate checklist (if needed) with this application.

Describe how your professional experience has prepared you to achieve the goals of the vocational training team.

LANGUAGES

Because training will be conducted in English, vocational training team members must be proficient in English. Please list the languages you speak (including English and your native language) and your proficiency level.

AGREEMENT

As a member of a Rotary Foundation Grant team for vocational training, I confirm and agree to the following:

1.I have read and agree to the terms and conditionsfor this vocational training team and will adhere to all policies therein.

2.I will provide a current personal health history and physical evaluation (within the last 12 months) as required for all applicants.

3.I will actively participate in the vocational training and work with my team as a cohesive group in order to ensure the success of the grant.

4.I will take an active role in the pre-departure orientation, including any necessary language and cultural training, to ensure that I am knowledgeable about the country(ies) to be visited and thoroughly acquainted with the aims, objectives, and ideals of Rotary and the purpose of the vocational training to further Rotary’s mission.

5.I will secure, for the trip, travel medical and accident insurance to cover medical care and hospitalization, emergency evacuation, and repatriation of remains with limits as outlined in the terms and conditions. This insurance must be valid in the country(ies) that I will visit during my participation and cover the periods from the date of departure through the date of return. Upon request, I will provide evidence of such coverage to the sponsors and The Rotary Foundation (TRF).

6.I agree to reimburse TRF any costs I have incurred if my behaviour warrants dismissal from the team. Additionally, in the event of dismissal, I shall be responsible for my own return transportation home and shall refund all funds received, including any interest earned.

7.All other matters relating to insurance, passports, inoculations, and financial readiness are my personal responsibility and not that of any Rotary club, district, RI, or TRF.

8.TRF will provide only for costs directly associated with grant implementation. I will have sufficient funds to meet my personal and incidental expenses while traveling.

9.TRF has final authority to select team members and may disqualify team members or alternates at any time, if deemed appropriate.

10.I have made the selection committee aware of my relationship (professional or personal) to any Rotarians sponsoring my application and/or any other participants on the team.

11.I will remain with the team throughout the term of the grant.

12.My behaviour during my travels with the team will reflect positively on Rotary, my sponsor club or district and my country.

13.I will not engage in dangerous activities for the entirety of the grant. Further, I understand and agree to the following:

a.While participating in this training, I may be involved in activities that could expose me to disease, injury, sickness, inadequate and unsafe public infrastructure, unsafe transportation, hazardous work conditions, strenuous physical activity, inclement weather, political unrest, cultural misunderstandings, issues resulting from noncompliance with local laws, physical injury or harm, and crime and fraud. I understand these risks and assume all risks involved with this training.

b.If I, because of serious illness or injury, am unable to complete the terms of this agreement and must return home, TRF shall pay to arrange for transportation home, but only to the extent that there is no other valid and collectible insurance available. RI/TRF shall not assume any additional costs, including the cost of any medical care or treatment, now or in the future, including, but not limited to, additional costs associated with having inadequate repatriation of remains or emergency medical evacuation insurance coverage.

c.I am solely responsible for any and all costs and damages for any illness, injury, or other loss (including loss of consortium and emotional loss) incurred or suffered participating in, traveling to, or traveling from the training, or otherwise related to the provision of the grant.

14.I will not engage in activities that could unnecessarily endanger or threaten my health, safety, or well-being or those of other participants (such activities would include, but not be limited to, skydiving, bungee jumping, extreme sports, operating heavy machinery, excessive drinking, and illegal drug use). I am solely responsible for my actions and property while participating in, and traveling to and from, the training.

15.I am responsible for all costs not covered by the grant. I agree to defend, indemnify, and hold harmless RI and TRF, including their directors, trustees, officers, committees, employees, agents, associate foundations and representatives (collectively RI/ TRF), from and against all claims (including, without limitation, claims for bodily injury or property damage), demands, actions, damages, losses, costs, liabilities, fines, expenses (including reasonable attorney’s fees and other legal expenses), awards, and judgments asserted against or recovered from RI/TRF arising out of any act, conduct, omission, negligence, misconduct, unlawful acts, or violations of any of the terms and conditions that apply to this grant. The foregoing includes, without limitation, injury or damage to the person or property of RI/TRF, or any third party, whether or not subject to any policy of insurance.

16.I will participate in club and district activities as requested by my sponsors.

17.TRF may share my name and contact details with other vocational training teams and Rotary districts upon request. Unless I indicate otherwise in writing, by submitting photos in connection with any report, I hereby give publication rights to RI, TRF, for promotional purposes to further the Object of Rotary and the mission of Mercy Ships, including but not limited to RI, TRF, publications, advertisements, and websites. I also authorize RI and TRF to share photos from reports with Rotary entities for promotional purposes to further the Object of Rotary.

18.If I travel after the end of the training, I will return to my sponsoring district within four weeks after the grant is completed.

19.I will abide by all TRF decisions related to travel safety. Therefore, if TRF determines, in its sole discretion, at any point in the grant period that my safety in the country where I am serving could be at risk, TRF may require that I return home immediately. In such instances, I agree further to abide by TRF’s decision as to subsequent availability of a grant.

20.I agree that my spouse or other family members, who are not approved members of the team, will not accompany the team during the term of the grant under any circumstances.

21.I will submit a final report two months after completion of my training period and will send copies of my report to TRF and the sponsoring Rotary clubs or districts. I understand that this report will be shared with Mercy Ships.

Only the laws of the State of Illinois, USA, without reference to its conflicts of laws principles, shall govern all matters arising out of or relating to this agreement, including, without limitation, its interpretation, construction, performance, and enforcement. Any legal action arising out of or relating to this agreement must be brought in either the Circuit Court of Cook County, Illinois, USA, or the federal District Court for the Northern District of Illinois. I consent to the exclusive jurisdiction of these courts and their respective appellate courts for the purpose of such actions. Nothing herein prohibits a party that obtains a judgment in either of the designated courts from enforcing the judgment in any other court. Notwithstanding the foregoing, TRF may also bring legal action against me in any court with jurisdiction over me.

Please check.

I have provided an electronic copy of my curriculum vitae or résumé with this application.

I have provided a signed copy of the Code of Conduct with this application.

I have provided completed health history and physical evaluation forms with this application.

Name (please print):

Signature (mandatory):

Date:

Please return this completed form and all attachments to the relevant VTT Committee member as stated on the Application Information form.

FRIEND REFERENCE FORM

Please fill in your name and address and give to a friend to complete.

Name:

(last/surname) (first) (middle initial)

Address:

Number and Street

City State/Province Country Postal Code

INSTRUCTIONS: Please be honest in your appraisal of this applicant. We encourage you to share your comments with the applicant; however, we will keep this information confidential.

1.How long and in what association have you known the applicant?

2.Please evaluate the applicant in the following areas:

•Character:

•Skills, abilities, strengths, and talents:

•Ability to adapt to new situations and difficult circumstances:

Your Name: Address:

Title:

Primary phone:

To the best of my knowledge, all information shared in this reference is correct and accurate.

Signature: Date:

EMPLOYER REFERENCE FORM

Please fill in your name and address and give to your current employer to complete. If you are not currently employed, please ask a former employer or mentor to complete this form and send it along with an explanation.

Name:

(last/surname) (first) (middle initial)

Address:

Number and Street

City State/Province Country Postal Code

INSTRUCTIONS: Please be honest in your appraisal of this applicant. We encourage you to share your comments with the applicant; however, we will keep this information confidential.

1.How long and in what association have you known the applicant?

2.Please evaluate the applicant in the following areas:

•Character:

•Skills, abilities, strengths, and talents:

•Ability to adapt to new situations and difficult circumstances:

Your Name: Address:

Title:

Primary phone:

To the best of my knowledge, all information shared in this reference is correct and accurate.

Signature: Date: ______