JustWorks: Civil Rights Journey 2012

Deadline: June 3, 2012

Dates and logistics

The JustWorks: Civil Rights Journey will begin in Atlanta, Ga. Please plan to arrive after noon on Sunday, July 22. Participants will depart from from Atlanta on Sunday, July 29, after 6:00 p.m., or may pay for additional night's stay and fly out on Monday, July 30.

Learn more about the JustWorks: Civil Rights Journey.

Before you fill out the following application, please consider associated costs beyond the participation fee.

Flights

Participants are responsible for purchasing their own airfare. The cost to fly to within United States is generally under $400. We encourage you to talk to family, friends, and community members about donating frequent flyer miles.

Applying by phone

To complete this registration form by phone, please call 617-301-4326, between 10 a.m. and 4:30 p.m. EST on weekdays. If a staff member in the UUSC College of Social Justice is not available, we will do our best to return your call on the same day.

1. First Name *This question is required

2. Last Name *This question is required

3. Address *This question is required

Street/PO Box
Apartment/Suite #
City
State
Zip
Country

4. Contact Info *This question is required

Primary Phone Number

5. Email Address *This question is required

E-mail Address

6. Gender (This information is used only for housing arrangements.)

7. Birthdate *This question is required

calendar

8. T-Shirt Size *This question is required

9. If you are affiliated with a UU congregation, which one?

10. If you have participated in a JustWorks or JustJourneys trip with UUSC, which ones did you participate in?

11. Are you a member of UUSC? *This question is required

Yes
No

12. We strive to create an intentionally diverse community. Are there any identities that you hold that you would like to bring to our attention?

13. Please list a personal reference to whom you are not related. *This question is required

Name
Relationship
Phone
E-mail

14. Please describe any social-justice work or activism you've participated in previously.

15. After the trip, how will you share what you've learned during this experience?

The following is a general health questionnaire. This information will be kept private but may be shared amongst the trip organizers, the participant-selection committee, and those in UUSC's emergency response team. All personnel are bound by UUSC policies to keep your health information private.

16. Please describe your general state of fitness, including any physical limitations and/or restrictions, disabilities, allergies, etc.

17. Do you have any of the following or have you ever experienced issues related to them? If you answer Yes to any, please add notes in the next question. *This question is required

17. Do you have any of the following or have you ever experienced issues related to them? If you answer Yes to any, please add notes in the next question. *This question is required	Yes	No
Anaphylactic Shock
Cardiac Conditions
Diabetes
Asthma
Medicated Mental-Health Issues
Allergies to Medications
Food Allergies
Substances Present in a Tropical Climate

18. If you answered yes to any of the above, please explain here.

19. List any medications, prescription or over-the-counter, that you are currently taking and for what condition. If other medication is not take orally, please list how it is administered.

20. Dietary Preference

Vegetarian
Vegan
Kosher

21. Are there any other medical or dietary needs that we should be aware of?

22. All JustWorks trip participants are required to have health insurance. Will you have health insurance by the start of the trip that will cover medical expenses incurred while abroad?

Yes

23. Please enter your health insurance provider information.

If you do not have this information readily available, please fill in what you can remember and submit the form. You can email your complete health insurance information to justworks@uusc.org when you have it available.

Insurance Policy Holder (If you are holder, write "self.")
Insurance Company
Plan Name
Address for Insurance Company
Telephone Number for Insurance Company
Policy Number or Insurance ID Number
Group Number
Name of Primary Care Physician
Phone Number of Primary Care Physician

24. First Emergency Contact *This question is required

First Name
Last Name
Relationship
Primary Phone
E-mail

25. Second Emergency Contact *This question is required

First Name
Last Name
Relationship
Primary Phone
E-mail

26. Would you like us to periodically update these people with nonemergency information like trip status and timelines (e.g., arrival at site, departure)?

Yes
No

27.

Please write an essay explaining your interest in this opportunity, describing relevant skills and life experiences you would bring to it, and demonstrating your commitment to social justice. What interests you about this specific program? What do you hope to gain from this experience? How do you imagine utilizing the experience when you return home? (300-600 words)

Recommendation: Rather than write your essay responses directly into the online application, we recommend you compose your response in a word processor, and when you are finished, cut and paste it into the field provided when the rest of the form is ready to be submitted. This will reduce the chance of lost data that sometimes happens with web-based forms.

*This question is required

28. How did you hear about this JustWorks trip?

In consideration of the opportunity afforded me to volunteer in the Unitarian Universalist Service Committee JustWorks Program (hereafter referred to as "UUSC"), and in light of the aims and purposes of the service provided by UUSC in organizing this project, I agree to participate in the trip; and I waive any right or cause of action arising as a result of my participation in said project from which any liability may or could accrue against UUSC, its officers, employees, and directors, either individually or collectively. Without limiting the generality of the foregoing, I agree that this waiver shall include any rights or causes of action resulting from personal injury to me or damage to my property sustained in connection with my activities for the trips. Therefore, I agree to assume all risks.

I understand UUSC assumes no responsibility for the loss of or damage to personal equipment or property brought to the work site by a participant or staff member.

I understand the participants must have working knowledge of spoken and written English. I grant permission for UUSC to use any quotations, photographs, or videotapes of me during the trip for promotional purposes.

I understand that opportunities to participate in UUSC events are limited and applications are necessarily competitive. Applicants will be accepted for participation based on their commitment to social-justice work as demonstrated by their words and their actions; the skills, attitudes, and life experiences they bring to the experience; and the limitations of any physical or medical conditions that may affect their own safety or those of others given the conditions and circumstances of the specific trip for which they are applying. I understand that UUSC has the right to accept, deny acceptance, or withdraw acceptance of any applicant at any time up to and including the trip itself, at its sole discretion. In the event UUSC withdraws acceptance, UUSC will make all reasonable efforts to reimburse applicants for any nonrefundable expenses related to trip planning and preparation (e.g., airfare).

If any sentence, phrase, paragraph, or section of this waiver is found to be invalid or ineffective by any court of competent jurisdiction, such decision shall not affect the validity or the effectiveness of the remaining portions of this participant statement or any part thereof.

29. Please enter your name as a digital signature, indicating you have read and agree to the above statements. *This question is required

Please click the Submit button below to send this Application in.