UUCSJ Journey Registration Form

UUCSJ Journey Registration Form

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This form is only for registering for one of UUCSJ's already scheduled journeys. If you are looking to organize a journey for your group or congregation, please contact us at info@uucsj.org.

Program Information

Which program would you like to participate in?

Registrant Information

First Name

Last Name

Street/PO Box

City

State

Country

Zip/Postal Code

Primary Phone Number

###-###-####

Email Address

Birthday

Month

Day

Year

Religious Affiliation

What is your religious affiliation? (Check all that apply)

Please specify:

In which region is your congregation located?

Which New England UU Congregation are you affiliated with?

If your congregation is not listed, select other

Which Mid-Atlantic UU Congregation are you affiliated with?

If your congregation is not listed, select other

Which Midwest UU Congregation are you affiliated with?

If your congregation is not listed, select other

Which South Atlantic UU Congregation are you affiliated with?

If your congregation is not listed, select other

Which South Non-Atlantic UU Congregation are you affiliated with?

If your congregation is not listed, select other

Which Mountain UU Congregation are you affiliated with?

If your congregation is not listed, select other

Which Pacific UU Congregation are you affiliated with?

If your congregation is not listed, select other

Which Canadian Congregation are you affiliated with?

If your congregation is not listed, select other

Which International Congregation are you affiliated with?

If your congregation is not listed, select other

Please specify:

How would you describe your racial background?

Please specify:

Are you Hispanic/Latinx?

YesNo

What is your gender identity?

Please specify:

Pronouns

Please specify:

Are there other aspects of your identity that you would like to share with us?

Occupation

Other Occupation

Please describe your general state of fitness, including any physical limitations and/or restrictions, disabilities, allergies, etc. In what physical activity do you regularly participate to stay fit and healthy?.

Please note that this is to give us a general sense of your ability with regards to the physical requirements of the trip. More detailed information about medical conditions, allergies, and medications will be requested upon preliminary acceptance into the program

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 trip? What do you hope to gain from this experience? How do you imagine utilizing the experience when you return home?

Financial Information

The cost (including lodging, in-country flights, food, etc.) for your trip will depend on the destination and length of stay. Please refer back to the appropriate Journey page (ex: https://uucsj.org/el-salvador/) to find the specific cost of your trip.

Through the generosity of our donors, some limited need-based financial aid may be available. Would you like to apply for a reduced fee?

YesNo

Annual Household Income

Include child support, alimony, government assistance, etc.

Current value of cash, savings and checking accounts

Do you own your own home?

YesNo

Total value of your home

Total debt on your home

Is there any other information relevant to your financial situation that you would like to share?

Trip Requirements

Please read the following carefully and check that you understand and agree below.

1.) I understand that I am required to have had a tetanus shot within 9 years of the trip start date.

2.) I understand that UUCSJ strongly recommends that in advance of my program, I review the Center for Disease Control's immunization recommendations for my destination; and suggest that I may wish to consult a travel clinic for advice.

3.) I understand that I am required to have health insurance that covers me in the destination country for the duration of the trip (Medicaid, Medicare, and VA plans do NOT cover internationally - if one of these is your regular plan, you will need to purchase supplemental health insurance).

4.) I understand that it is my responsibility to make sure my health insurance covers the destination, and that I will provide my insurance details to UUCSJ prior to departure.

5.) I understand that I am required to have a current passport and may need to obtain a visa before the program start date for international journeys. I understand that UUCSJ can assist me with some of the information needed for the visa application, but that applying and obtaining the visa is my responsibility.

I have carefully read the statements above and agree to each.

How did you hear about this UUCSJ Program?

Other:

UUCSJ tries to offer financial aid as much as possible. Would you consider donating? 100% of your pledge would go directly to the scholarship costs of participants who qualify for financial aid.

Electronic Signature (Type Name)

Today's Date

Parent/Guardian Electronic Signature if under 18 years of age (Type Name)

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Contact Information