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AB Faculty/Staff Application

Warning: This form will time out.  Please read the essay questions and write your answers in a word processing document.  When you are done answering all of the questions, copy and paste your answers into this form, and then fill out the rest of the form. You will know if your application has submitted correctly if you are directed to a message about signing up for an interview.
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First Name
Last Name
Nickname
Age
Gender
Male
Female
Local Address
City
State
Zip Code
Cell Number
 
Email
 
Employee I.D. #
T-Shirt Size
 
Special Health Considerations (ie Diabetes, allergies to medication, etc)
Special Food Considerations (vegetarian, no red meat, etc)
FOOD POLICY: By signing this statement, I understand that this is a group travel experience and we cannot always accommodate special dietary needs. It is advised that those who do have special dietary needs bring food with them and/or buy food for themselves on the trip. The Alternative Breaks program will not cover extra meals for those with dietary restrictions. Also, some trips are not located in areas where food can be purchased. Food provided will most likely be unique to the location of the trip.
Digital Signature:
 
Health Insurance Information
Health Insurance Carrier
Identification/Group #s
Insurance Phone Number
 
 
Emergency Contact Information (We reserve the right to contact your Emergency Contact at our discretion)
Emergency Contact
Relationship to You
Email
 
Primary Contact Number
 
Additional Contact Number
 
 
IDENTIFICATION: I understand that if I am placed on a domestic trip (traveling by air) I am required to bring a government issued ID or Drivers License. I understand that if I am placed on an international trip I am required to bring a government issued passport that does not expire at least 6 months prior to return to the U.S.
Digital Signature:
I have a current passport
YesNo
Passport Expiration Date
Pick date
Clear selection
Name as it appears on Passport (State ID if only applying for domestic trips)
Some trips require participants to drive rental cars. Please indicate if you are willing to drive, over 21, and have a clean driving record?
YesNo
The Alternative Breaks program is alcohol and other drug free. This is required for the safety and well-being of all participants, the group as a whole, and the community in which they are serving. These policies will be discussed with everyone who is chosen to participate and full compliance is a mandatory requirement.
Digital Signature:
COMMITMENT: By signing this statement, I am committing to all aspects of AB preparation, participation and follow-up. All staff members are asked to participate in at least 2 pre-trip meetings setup by the trip leaders(please coordinate with the leaders a for an appropriate time). Staff members are also encouraged to participate in the Stories of Solidarity on March 16th.
Digital Signature:
I can attend the ENTIRE AB Staff training, on Saturday October 22nd 9am-2pm.
YesNo
If no, please explain
 
Site Preference Rankings- Refer to "Trip Schedule" for descriptions - Please Select Most Appropriate (All Required)
Winter Break Jan 2nd-Jan7th
Immigration- San Diego/East LA
HighlyHappilyIndifferentRather NotNo Way
Immokalee/Seminole-Florida
HighlyHappilyIndifferentRather NotNo Way
Spring Break: Feb. 25th-March 3rd
Youth & Families-Quito, Ecuador
HighlyHappilyIndifferentRather NotNo Way
Indigenous Peoples-San Lucas Toliman, Guatemala
HighlyHappilyIndifferentRather NotNo Way
Refugee Services-Dallas, Texas
HighlyHappilyIndifferentRather NotNo Way
Sustainable Development-Bocas del Toro, Panama
HighlyHappilyIndifferentRather NotNo Way
Food Justice-Sacramento, CA
HighlyHappilyIndifferentRather NotNo Way
Environmental Conservancy-Catalina Island, CA
HighlyHappilyIndifferentRather NotNo Way
Indigenous and Rural Communities-Morelos, Mexico
HighlyHappilyIndifferentRather NotNo Way
Disaster Relief-New Orleans, Louisiana
HighlyHappilyIndifferentRather NotNo Way
Veterans' Services-Colorado Springs, Colorado
HighlyHappilyIndifferentRather NotNo Way
Homelessness & HIV-Staten Island, New York
HighlyHappilyIndifferentRather NotNo Way
Special Needs Services-Lima, Peru
HighlyHappilyIndifferentRather NotNo Way
Summer Break
Medical Issues-Kingston, Jamaica
HighlyHappilyIndifferentRather NotNo Way
Peace Activism-Israel/West Bank
HighlyHappilyIndifferentRather NotNo Way
I have discussed my participation in the Alternative Breaks program with my supervisor and he/she approves of my partcipation during the following breaks (check all that apply):
Winter
Spring
Summer
Supervisor's name:
Supervisor's email:
 
Supervisor's phone:
 
Have you ever been on an AB trip?
YesNo
(If yes) Location?
(If Yes) Date
 
SHORT ESSAY QUESTION In the space provided, please respond to the following questions:
Why are you applying to participate in the Alternative Breaks program?
Staff and faculty participants in the AB program are asked to support and empower the student trip leaders as they navigate the challenges of peer leadership while traveling in a different culture. Please explain how you imagine taking on this role during an AB trip.
Please list any specific skills you have that are relevant to the Alternative Breaks program (e.g. language, past community service, leadership experience, etc.).