Table Of ContentAmbassador & Chapter Trek Program
Document Check List
Please complete and turn in the following items to buildOn
at least 60 days prior to your departure.
buildOn
Attn: Melissa Sanseverino
P.O. Box 16741
Stamford, CT 06905
Contact Melissa at 203.585.5391 or
[email protected] with questions.
o Parent Permission to Travel (if under 21)
o Trek Release Form
o Emergency Contacts
o Trek Covenant
o Medical History
o Asthma Action Plan*
o Confidential Medical Form*
o Medical Clearance Form*
o Medications Checklist
o buildOn Gift Policy
o buildOn Site Return/Extension Policy
o Copy of Passport
o Copy of Flight Itinerary
*must be signed by doctor
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Trek for Knowledge
~PARENT PERMISSION TO TRAVEL~
Required of participants under age 21
I, ______________________________________________________________________
Father, Mother, or Legal Guardian (Please Circle and print name above)
domiciled at ______________________________________________________________
Address (City, State, Zip Code)
Do hereby AUTHORIZE our son/daughter,
_______________________________________________
Full Name (print)
to travel internationally on __________________ to _____________ for the purpose of participating in
(Dates of Travel) (Country)
the buildOn Trek for Knowledge program sponsored by buildOn, INC., and as part thereof, to travel to and from
buildOn school construction sites via transportation arranged by buildOn. I confirm my understanding that this Trek for
Knowledge program and this trip is not sponsored by or affiliated with the Public Schools or governed by the Public
Schools travel policy.
________________________________________
Father, Mother, or Legal Guardian Signature Date:
STATE OF _______________________ COUNTY OF _____________________
On _________________________, before me, _________________________________ a
(insert name and title of the officer)
notary public, personally appeared ________________________________________,
(Father, Mother, or Legal Guardian)
who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed
to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their
authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), executed the
instrument.
I certify under PENALTY OF PERJURY under the laws of the State of ___________ that the foregoing
paragraph is true and correct.
Signature: ____________________________
WITNESS my hand and official seal.
(seal) Name (printed): ________________________
My commission expires: __________________
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Trek for Knowledge
RELEASE FORM
NOTE: Please carefully read this Release Form. Only sign this form after you and your parents or
guardians have read it carefully and fully understand its contents. This is a legally binding agreement
which contains a release which will reduce or eliminate your legal rights in certain events.
I, ______________________________________, hereby request that I be allowed to participate in the
buildOn Trek for Knowledge Program (the “Trek”) sponsored by buildOn, Inc. (“buildOn”). As part of the Trek, I
will travel to and from buildOn school construction sites in foreign countries via transportation arranged by
buildOn to work on the construction of one or more schools and to participate in cultural events while there.
I and my parents/guardians agree that:
1. I will secure all of the inoculations required by buildOn prior to my departure date for the Trek, as well as a
passport or other travel documents necessary for foreign travel to my destination.
2. I will be bound by buildOn’s Trek’s rules and regulations pertaining to the conduct of participants in the
Trek including, without limitation, any standards of personal conduct that would apply to me.
3. I will voluntarily return to the United States when directed to do so by buildOn for health or any other
reasons, including my failure to comply with buildOn’s rules and regulations or actions by me that, in the
sole judgment of buildOn, reflect poorly on buildOn.
4. I will fully advise buildOn as to all factors relating to my medical and emotional health and I will not submit
inaccurate and/or incomplete information about my medical and emotional health history and understand
that if I do, I may be removed from the Trek.
5. I will promptly notify buildOn personnel if any substantial change should occur regarding my medical or
mental health prior to or while on the Trek.
6. I am now covered, and at all times while participating in the Trek will remain covered, by health insurance
and the information regarding my health insurance is accurately disclosed in the Medical Form I delivered
to buildOn.
7. buildOn will not be responsible for any costs incurred in connection with any medical care or hospitalization
incurred by me prior to, while on or after my return from the Trek.
8. I have been informed that the Trek
a. Involves strenuous activities;
b. May expose me to many risks, including but not limited to, unpredictable or harsh weather, extreme
temperature, lightning, diseases, poisonous plants, insects, wild animals, hazardous terrain, crime or
unsafe road conditions; and
c. Will take place in remote and/or underdeveloped areas in one or more foreign countries and medical
services may not be immediately available to me in the event of a medical emergency and, if
available, may not be equivalent to the level of medical services available in the United States.
9. I have read this release and am fully understand familiar its contents.
I confirm my understanding that this Trek is not sponsored by or affiliated with any public or private school nor
is it governed by any travel policies of such school or school system.
I hereby consent to the participation in interviews, the use of quotes, and the taking of photographs, images or
audio or video recordings of me by buildOn or its assigns, licensees, and designees, and hereby give buildOn
(and its assigns, licensees, and designees) the irrevocable right to use my name, voice, likeness, image,
and/or biographical information for promotional, marketing or other publicity purposes including use in print, on
the Internet, and all other forms of media now known or hereinafter created (collectively, the “Materials”). I
hereby waive any right to inspect or approve any uses that may be made of the Materials. I agree that the
Materials shall constitute buildOn’s sole property, with full right of use and disposition in any manner
whatsoever. I also hereby completely release, discharge and agree to hold harmless buildOn and its officers,
directors, employees, assigns, licensees, designees and all persons acting under its permission or authority
from any and all claims, demands, and liabilities whatsoever that I may have in connection with the above,
including without limitation claims for defamation, violation of any right of publicity and/or invasion of privacy. I
waive any and all claims to any compensation by buildOn in connection with use of the Materials.
I and my parents/guardians agree:
(a) To WAIVE any and all claims that I or they may now or in the future have against buildOn, its officers,
agents, employees, directors, shareholders, affiliated entities, subsidiaries, agents, volunteers, all insurers,
and all sponsors (hereinafter collectively referred to as "Releasees"), for any and all loss, damage, injury or
expense that I or they may suffer as a result of my participation in the Trek, due to any cause whatsoever,
including but not limited to negligence on the part Releasees.
(b) To RELEASE FROM LIABILITY AND HOLD HARMLESS Releasees for any and all loss, damage,
injury or expense that I or they may suffer as a result of my participation in the Trek, due to any cause
whatsoever, including but not limited to negligence on the part Releasees.
(c) To VOLUNTARILY ASSUME AND ACCEPT all known and unknown risks of personal injury and/or
death while participating in the Trek.
(d) To NOT FILE ANY CLAIM OR LAWSUIT against Releasees.
In the event that an action is commenced against Releasees by me or by my parents/guardians or on my or
their behalf, I and my parents/guardians agree to defend and indemnify said Releasees.
This Release shall be construed in accordance with and governed by the laws of the State of Connecticut
excluding any choice of laws rule or principle that would result in the application of the laws of any other
jurisdiction and exclusive jurisdiction for any matter arising hereunder shall be in the courts located in Fairfield
County, Connecticut.
If I am under the age of twenty-one (as indicated below), my parent(s) and/or guardian(s) have signed below
and they jointly and severally consent to my participation in the Trek and agree to all of the foregoing in
consideration of buildOn's acceptance of me in the Trek.
___________________ _____ _________________________ __________
Participant’s Name (printed) Age Participant’s Signature Date
IF UNDER 21 Years of Age:
__________________________ _____________________________ __________
Mother’s Name (printed) Mother’s Signature Date
__________________________ _____________________________ __________
Father’s Name (printed) Father’s Signature Date
__________________________ _____________________________ __________
Legal Guardian’s Name (printed) Guardian’s Signature Date
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Trek for Knowledge
~EMERGENCY CONTACTS~
Your medical history and background are important to us. We will keep copies of these documents at the
buildOn Office, as well as bring them with us during the Trek. Should an emergency arise, we will use the
information that you provide to manage the situation and select appropriate treatment.
In addition to the report of medical history forms that follow, please fill out the emergency contact information
below. Be sure to include both daytime and evening phone numbers for your contacts, when possible.
In the case of an emergency involving ______________________ ,
Trek Participant’s Full Name Here
Please contact the following individuals:
Name: __________________________ Relationship: _____________________
Phone #1: _______________________ Phone #2: _______________________
Best Time to Call: __________________ Best Time to Call:__________________
Email Address (if available): _________________________________________________
Name: __________________________ Relationship: _____________________
Phone #1: _______________________ Phone #2: _______________________
Best Time to Call:_________________ Best Time to Call:__________________
Email Address (if available): _________________________________________________
Name: __________________________ Relationship: _____________________
Phone #1: _______________________ Phone #2: _______________________
Best Time to Call:_________________ Best Time to Call:__________________
Email Address (if available): _________________________________________________
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Trek for Knowledge
~ TREK COVENANT~
The purpose of a buildOn Ambassador Trek is to allow individuals to:
Work side-by-side with villagers in helping them build a school
Live with a host family in a rural village and learn about their culture
Become energized by their ability to effect change in a developing country
Make a direct and lasting impact by bringing literacy to hundreds of people
Participant commitments:
Raise the necessary funds to build the school and cover all travel costs associated with the trip
Read the buildOn Trek guide and complete assigned homework
Follow buildOn guidelines for responsible travel while on Trek
Complete necessary paperwork according to the timeline in the informational packet
Live in a rural village and participate in the cultural exchange including:
- Living and working alongside the villagers to build their school
- Eating local foods
` - Sharing with the community and respecting the local culture and people
Obtain a valid U.S. passport, necessary immunizations, and visa (where applicable) prior to departure
Act as unofficial ambassadors for the United States and buildOn while in the country you are visiting
buildOn commitments:
Provide a Trek coordinator and translator to accompany your group
Arrange host families and supply food and a cook in the village
Arrange accommodations and transportation to/from the village
Purchase emergency evacuation insurance for participants and provide a vehicle for emergencies to stay in the
village at all times
Coordinate travel dates with school groundbreaking and construction
Offer support throughout the fundraising and pre-Trek process, including assistance with paperwork and visas and
all other logistics
I, undersigned, agree to the above-mentioned conditions for my participation as a team member on
buildOn’s Trek for Knowledge.
_______________________________ __________________
Trek Team Member’s Signature Date
Description:the buildOn Trek for Knowledge program sponsored by buildOn, INC., and as passport or other travel documents necessary for foreign travel to my
