Global Dental Relief Volunteer Application

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Helpful items for completing this application:
1. Copy of your passport
2. Copy of your Dental/Hygiene license (if applicable)
3. Personal physician and insurance information

IMPORTANT: If you are not from the U.S. or Canada, please e-mail your country coordinator for a credit card authorization form. Select "Credit Card via Phone" when completing the deposit at the end of this form.
PERSONAL INFORMATION

















VOLUNTEER INFORMATION







*There is an additional charge for single rooms. Please contact your country coordinator for details.




*GDR is unable to guarantee that latex-free gloves will be available in your clinic. If you have a latex sensitivity, we ask that you bring your own supply of 300 gloves. 

In 500 words or less.


BACKGROUND
Name Field of Study Graduation Year
High School
Undergraduate
Graduate
Post Graduate



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HEALTH INFORMATION












EMERGENCY CONTACT INFORMATION





SUPPLY BAG QUESTIONNAIRE
Volunteers traveling from the contiguous United States are expected to be available to carry a pre-packed bag of equipment and/or supplies to the clinic. We ask that volunteers limit their personal baggage to one checked bag and bring our bag of supplies as your second piece of checked luggage. GDR will reimburse you the cost of checking this bag as your first or second checked bag. 

Please note that we will not ask all volunteers to carry a bag, but if you are selected your country coordinator will communicate this with you in advance. The supply bag will be shipped to your home from GDR prior to your departure for the clinic. Supply bags are packed to be within the size and weight restrictions of the airlines and contains an inventory of contents in the side pocket.


If you are a dental professional and will be bringing additional donated supplies, please indicate the amounts you will be bringing below. Please note that we cannot used expired materials and write TBD if you are unsure at this time:





*We hand carry all equipment and supplies for the clinic from the United States. We need as much help as possible to get bags of equipment and supplies to the clinic. This is the least expensive, most reliable way to deliver items to the countries we work in. 

Release and Discharge: Agreement for Participants, Release and Discharge, Acceptance of Responsibility and Acknowledgement of Risks.                                                                                                                                                                                                                                                                                                                     This Document affects your legal rights. You must read and understand it before signing.

ACKNOWLEDGEMENT OF RISKS
I understand and acknowledge that the Volunteer Dental Project that I am about to participate in bears certain known and unknown risks which could result in injury, death, illness or disease, physical or mental or damage to myself, to my property or to third parties. I understand that there are risks inherent in the nature of travel itself including, but not limited to the hazards of traveling in mountainous terrain and underdeveloped areas, accident or illness in remote places without medical facilities, and travel by bus, automobile or other conveyance and accidents connected with their use.

I understand and acknowledge that the above list is not complete or exhaustive, and that there are other risks that may also result in injury, death, illness or disease, or damage to myself, to my property or to third parties.
ACCEPTANCE OF RISK AND RESPONSIBILITY
Being aware that travel to and working at the mobile clinic entails risks of injury to myself and a risk or injury to third parties as a result of my actions, I agree and promise to accept and assume all responsibility and risk for injury, death, illness or disease, or damage to myself or to my property arising from my participation in this Volunteer Dental Project. I accept the possibility of political activity and/or physical harm due to political unrest. I further accept the risk of harm arising from unforeseen natural disasters. I acknowledge that Global Dental Relief reserves the right to make last minute changes in locations, itineraries, or even to cancel a trip in the interest of my safety if deemed advisable at Global Dental Relief's sole discretion. 

I agree and promise to accept and assume all responsibility and risk for injury, death, illness or disease, or damage to third parties and their property arising from my participation in the Volunteer Dental Project. My participation in the Volunteer Dental Project is purely voluntary; no one is forcing me to participate, and I elect to participate with full understanding of the potential risks.
RELEASE
I hereby voluntarily release and forever discharge Global Dental Relief, its agents or employees from any and all liability, claims, demands, actions or rights of action, which are related to, arise out or, or are in any way connected with my participation in this Volunteer Dental Project, including specifically, but not limited to the negligent acts or omissions of Global Dental Relief, its agents or employees, partners or sub-contractors, and all other persons or entities, for any and all injury, death, illness or disease, and damage to myself, or damage to my property or to third parities. 

I further agree and promise to hold harmless and indemnify Global Dental Relief, its agents or employees, from all defense costs, including attorney’s fees, or from any other costs incurred in connection with claims for bodily injury or property damage which I may negligently or intentionally cause to third parties in the course of my participation in this volunteer project. 

I further agree and promise not to sue, assert or otherwise maintain or assert any claim against Global Dental Relief, its agents or employees, for any injury, death, illness or disease, or damage to myself or damage to my property arising from or connected with my participation in this Volunteer Dental Project or from any claim asserted against me by third parties.
PARTICIPANT INSURANCE BENEFITS
I understand and acknowledge that Global Dental Relief, will not provide me with any insurance coverage benefits and that it is my responsibility to purchase adequate insurance. I further understand that Global Dental Relief will provide information on obtaining said insurance, but it is my responsibility to apply for and purchase insurance coverage.

BOOKING TERMS AND CONDITIONS: Please read carefully.

Eligibility
You must be 18 years old or accompanied by a parent/guardian and in acceptable health to join one of our programs. Acceptance on a service program is subject to our review of your application. We retain the right to request medical clearance or any other information or to refuse any applicant for any project at any time for any reason whatsoever, at our discretion.
Pricing and Payment

Reservations are accepted and confirmed after Global Dental Relief receives a $700 non-refundable deposit and a completed and signed application form. Upon confirmation of your application, Global Dental Relief will issue a written Confirmation letter. It is at this time that a contract between Global Dental Relief and the client (any person traveling or intending to travel on a service program operated by Global Dental Relief) comes into existence. Final payment for your service project is due 90 days prior to departure. Global Dental Relief may treat an application as cancelled if the client fails to pay the balance by the due date. Once final payment is received, a final service project packet including last minute reminders, tickets and service program documents will be mailed.

Changing your Booking
There will be a $100 administration fee assessed per booking plus any additional costs incurred if you change your booking prior to 90 days before departure. Thereafter all changes will be subject to the charges below.
Cancellation of Booking

If you must cancel before departure, money will be returned less the cancellation fee as follows: 


Days Prior to Departure Fee: 

a) 90 & more days Retention of Deposit
b) 89-60 days 40% 

c) 59-30 days 70%

d) 29 days or less 100%

*Cancellation fees are calculated from the date written notification is received by Global Dental Relief. 
Late Bookings
Our volunteer service programs fill up very quickly, so we encourage sending in your application early. There will be a late booking fee of $50 assessed on any booking made 30 days or less before the departure date. Full payment plus the late fee should be paid by cashiers check.
If we cancel your program:
Global Dental Relief reserves the right to cancel a service program under any circumstance, however, we will not cancel a service program less than 4 weeks prior to departure except in the case of force majeure, consolidation or clients failure to pay the final balance. If Global Dental Relief elects to cancel a service project due to clients failure to pay the final balance, the deposit is non- refundable. Global Dental Relief is not liable for any penalty charges associated with connecting airfares, in the event that there is a change to a service program departure time, date or cancellation.
Trip Cancellation Insurance
Global Dental Relief strongly recommends that you purchase or prove that you have adequate trip insurance including: Trip Cancellation and Interruption, Emergency Medical Evacuation and Assistance, Accidental Death and Sickness and Loss of Baggage and Personal Effects.
Expenses Covered
Due to many factors beyond our control, such as currency fluctuations, exchange rates and so on, we reserve the right to change our prices without prior notice, even after you have signed up. Normal price increases are not passed on to clients who have already made a deposit on a service program. Should there be a price adjustment you will be notified at least 4 weeks prior to departure and will have the choice of canceling your service program at that time. Should you choose to cancel your service program due to price increase, you will receive a full refund less the $700 non-refundable deposit.
Participation and Requirements
Clients agree to accept the authority and decisions of Global Dental Relief employees, service program leaders and agents while on a service project with Global Dental Relief, its agents, contractors or suppliers. If such a person perceives that the health or conduct of a client at any time before, during or after departure appears likely to endanger the safe, comfortable and happy progress of a service program, the client may be excluded from all or part of the service program without refund or compensation from Global Dental Relief for portions of the service program missed or excluded from. In the case of ill health, Global Dental Relief may make such arrangements as it sees fit and recover the costs thereof from the client. If a client commits an illegal act he or she may be excluded from the program and Global Dental Relief shall cease to have any responsibility for them.
Global Dental Relief Responsibilities
Client bookings are accepted on the understanding that they are aware of the possible risks involved in adventure travel and that they undertake the service programs, treks or expeditions offered by Global Dental Relief of their own free will. Due to political and cultural differences as well as generally tougher physical conditions, travel to many areas of the world involves risks other than those we take in our daily lives. Global Dental Relief and its service program operators and agents place extreme importance on the safety of its clients. However, it is the clients responsibility to make themselves aware of the risks involved and to make their decisions accordingly. There will be no refund made for any unused services included in the price of the service program. Global Dental Relief shall not be liable for any delays, deviations or omissions from any service program caused by circumstances beyond its responsible control, nor for any direct or indirect consequences thereto. Global Dental Relief will not be liable to compensate its clients for associated expenses incurred as a result of their booking. Global Dental Relief only acts as an agent for the owners, contractors, suppliers of transportation and local operators / agents and or other related travel services and assumes no liability or responsibility for additional expenses howsoever caused arising directly or indirectly from the actions or omissions from such dependent parties, accidents, loss or damage to a person or property, delays, transport failures, strikes, war, force majeure, acts of God etc, over which it has no control. Arrangements so made by Global Dental Relief will be subject to any special terms imposed by the supplier of these services. Global Dental Relief accepts no responsibility for any action or activity undertaken by the client arranged independently of Global Dental Relief while on a service program. Global Dental Relief accepts no liability for any circumstance arising pursuant to the agreement constituted by acceptance of these conditions by the client.

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*If you are in the process of applying for a passport or renewing an expiring passport or Dental/Hygiene license please send to your country coordinator by e-mail when it is received. 

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For those outside the US/Canada, please select "via Phone" and e-mail your country coordinator.
BILLING INFORMATION (Must match the billing address connected to your credit card)






PAYMENT INFORMATION








$

OTHER FORMS OF PAYMENT
If you wish to pay by check, please mail a check for $700 payable to Global Dental Relief.

Global Dental Relief
2090 S. Grant St.
Denver, CO 80210
Please call the office during business hours to submit credit card information over the phone.
Monday - Friday 9AM - 5PM (MST)

303-858-8857