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Initiative Outdoor Study Abroad Program Application
Name:
Address:
Zip Code:
Citizenship:
Contact Numbers:
Email Address:
Birthday: (mm/dd/yyyy)
Gender:
Male Female
Height:
Weight:

Education:

Highest level of Education:
Most Current University:
Year of completion or estimated year of completion:
Major:
Course Selection: (Please select 1st, 2nd, 3rd, and 4th choice )
Kayaking and White Water Rafting (Spring 2013 - 15 weeks)
Backpacking and Canyoning (Fall 2012 - 12 weeks)
Mountaineering, Rock and Ice Climbing (Winter 2012 - 15 weeks)
Jangali Leadership Course (Summer 2012 - 5 weeks)

Parent or Legal Guardian Information:

Mother/Legal Guardian:
Name:
Address:
Zip Code:
Contact No.
Email Address:


Father/Legal Guardian:
Name:
Address:
Zip Code:
Contact No.
Email Address:


Outdoor experience:

For the following please provide your knowledge, skill level, and experience. Please select your comfort level on a scale of 1 (no experience) to 5 (skilled enough to guide).
Mountaineering: 1 2 3 4 5
Rock Climbing: 1 2 3 4 5
Canyoning: 1 2 3 4 5
Kayaking: 1 2 3 4 5
River Rafting: 1 2 3 4 5
River Navigation: 1 2 3 4 5
Backpacking: 1 2 3 4 5
Camping: 1 2 3 4 5
Wilderness Survival: 1 2 3 4 5
First Aid: 1 2 3 4 5
Map Reading and Navigation: 1 2 3 4 5


Short Answer Questions (One to two sentences):

What are three leadership qualities you have?

What are three weaknesses you have in leading?

What has been your best outdoor experience?

What has been your worst outdoor experience?

Have you ever been rescued before? If so, describe the situation and what you learned from the experience.


Essay Questions:

Describe your reactions to stress and how you manage stressful situation, including a specific example. Be honest!

Discuss a personal experience either in travel or in the outdoors that has influenced your decision to come to Nepal and participate in this course.

Health and Dietary Information:
Please indicate your level of physical activity on a scale of 1-10.
1 = very little activity, 10 = very active, comfortable trekking for many days

1 2 3 4 5 6 7 8 9 10

Do you smoke? If so, how many cigarettes/packs a day?

Do you drink alcoholic beverages? If so, how often and how many drinks per day?

Do you have Asthma or Allergies? If so, please explain cause and severity in detail.

Do you have specific dietary preferences? (Vegetarian, kosher, vegan, etc.) Are you flexible? Please explain in detail.

Participant Agreement, Release and Assumption of Risk

Please read and understand the document before signing it. You may not participate in any I.O. program without this form having been completed and signed.

In consideration of the services of Initiative Outdoor Pvt. Ltd. (I.O.) and their representative agents, owners, officers, directors, members, volunteers, participants, employees, and all other persons or entities acting in any capacity on their behalf, I hereby agree to release, indemnify and discharge I.O. on behalf of myself, family members, guardian, personal representatives and estate as follows:

I acknowledge that outdoor adventure based activities such as camping, rafting, kayaking, trekking, hiking, rock climbing, canyoning, caving and mountaineering entail known and unanticipated risks that could result in physical or emotional injury, trauma, paralysis, death, illness and disease or damage to myself, to property or to third parties. I understand that such risks simply cannot be eliminated without jeopardizing the essential quality of the activity.

The risks include but are not limited to:

  1. Weather conditions that may change quickly, including tempreature, precipitation, wind, lightening, excessive heat and sun
  2. Over exertion, dehydration, hypothermia, hyperthermia and emergency sunburn
  3. Contact with land and aquatic animals
  4. Difficult terrain or walking conditions
  5. Improper first aid, emergency treatment or other attempted rescue services, including evacuation and the unavailability of life saving services or immediate medical attention in the case of injury.
  6. Exposure to contaminated or polluted water
  7. The consumption of tainted food or drink during the course
  8. My own physical condition, acts or omissions, including my levels of expertise or experience in the various activities throughout the course;
  9. My own or other participants' attempts to exceed abilities or acting in a reckless manner;
  10. My own or that of other participants' failure to follow I.O.'s safety guidelines and instruction of its instructor
  11. My own and others' improper use of equipment;
  12. Inadequate repair or maintainence of equipment used by I.O.;
  13. Failure of the equipment supplied or used by I.O.;
  14. Vehicular or pedestrain accident while being transported or walking from/to activity sites
  15. Error or negligence on the part of Initiative Outdoor Pvt. Ltd and its instructors, including adequate instruction or assistance.

Furthermore, Initiative Outdoor Pvt. Ltd employees have difficult jobs to perform. They seek safety, but are not infallible. They might be unaware of a participant's fitness abilities. They might misjudge the weather or other environmental conditions. They may give incomplete warnings or instructions, and the equipment being used might malfunction.

  1. I expressly agree and promise to accept and assume all of the risks existing in the activities. My participation in this activity is purely voluntary, and I elect to participate in spite of the risks.
  2. I understand that no major medical insurance benefits will be provided by I.O. during this course. I certify that I have adequate insurance to cover any injury or damage I may cause or suffer while participating,and I agree to bear the costs of such injury or damage myself. I further certify that I am willing to assume the risk or any medical or physical or psychological condition I might have.
  3. In the event that i damage, lose, or destroy any I.O. property or equipment supplied by them, I agree to compensate I.O. for the full retail value of the property, per the current price.
  4. I voluntarily release, forever discharge and agree to indemnify and hold harmless Initiative Outdoor Pvt. Ltd. from any and all liability, claims, demands or causes of action which may be in any way connected with my participation in any I.O. activity of the use of equipment of facilities, including all such claims which allege negligent acts of omissions of I.O., its instructors or staff.

Refund Policy
If you cancel the course at least a week in advance from the course date there will be refund of all tuition paid not including the non-refundable deposit. If you wish to cancel the course within 1 week of the actual date of fail to show up for the course there will be no refund under any circumstances. Once a course has commenced and you leave the course early for any reason, either voluntary or involuntary, there will be no refund under any circumstances.

I HAVE HAD SUFFICIENT OPPORTUNITY TO READ THIS ENTIRE DOCUMENT. I HAVE READ AND UNDERSTOOD IT, AND I AGREE TO BE BOUND BY ITS TERMS.

Participant's signature: ................................ Printed Name: ................................

Mother/Guardian's signature: ................................... Printed Name: ................................

Date: ...........................

Father/Guardan Signature: ....................................................................... Printed Name: ............................

Date: ...........................

Course Regulations and Conditions:
Please initial next to the following statements.

I understand Initiative Outdoor reserves the right to dismiss me from the course at anytime for any reason. I understand if I am dismissed from the course I will not be given a refund and will no longer be the responsibility of Initiative Outdoor in any way, including financially.
I understand this is a tobacco free course and agree not to possess or use any tobacco products during the course. I understand failure to comply with this agreement means I will not be allowed to continue in the course, will be dismissed immediately, and I will not receive a refund. I understand I will no longer be the responsibility of Initiative Outdoor in any way, including financially.
I understand this is a alcohol free course and agree not to possess or consume any alcoholic beverage during the course. I understand failure to comply with this agreement means I will not be allowed to continue in the course, will be dismissed immediately, and I will not receive a refund. I understand I will no longer be the responsibility of Initiative Outdoor in any way, including financially.
I understand this is a recreational drug free course and agree not to possess or consume any recreational drug during the course legal or illegal. I understand failure to comply with this agreement means I will not be allowed to continue in the course, will be dismissed immediately, and I will not receive a refund. I understand I will no longer be the responsibility of Initiative Outdoor in any way, including financially.

Participant's signature: ................................ Printed Name: ................................

Mother/Guardian Signature: ................................... Printed Name: ................................

Date: ...........................

Father/Guardian Signature: ................................... Printed Name: ................................

Date: ...........................


Read Agreement

I have read the agreement and accept terms and conditions set by Initiative Outdoor.
 
 
 
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