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Please select your trip dates and fill out the following form to register to Volunteer with BIO! *Payment instructions to secure your spot and trip details will be emailed to you after registration (Paypal is available for those that wish to use it). *Please note - Airfare is not included. | Seleccione las fechas de su viaje y complete el siguiente formulario para registrarse como voluntario en BIO! *Las instrucciones de pago para asegurar su lugar y los detalles del viaje se le enviarán por correo electrónico después del registro (Paypal está disponible para aquellos que deseen usarlo). * Nota: la tarifa aérea no está incluida.

Last Name | Apellido*

First Name | Primer Nombre*

Middle Initial | Inicial del Segundo Nombre

Date of Birth | Fecha de Nacimiento*

Gender*

Female

Male

Other

Email*

T-Shirt Size | Talla de Camiseta*

Address | Dirección*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Passport #*

Mobile Phone*

Home Phone

Emergency Contact Name | Nombre del Contacto de Emergencia*

Relationship | Relación

Emergency Contact Phone | Número de Teléfono de Contacto de Emergencia*

WAIVER OF LIABILITY

(please read carefully)

I certify that my answers are true and complete to the best of my knowledge. I understand that any falsified statements on this Application, or omissions of fact, either on this Application or during the pre-departure process, will result in my application being rejected. I acknowledge that my purpose in participating in this expedition is to learn more for the ultimate purpose of supporting the people of the Dominican Republic, and more specifically the beneficiaries of the programs. In respect for my hosts and the beneficiaries, I will make effort to communicate any changes to my travel plans or schedule with the greatest advanced notice possible.

PRECAUTIONARY CORONAVIRUS DISEASE (COVID-19) PANDEMIC WAIVER AND RELEASE OF LIABILITY (type initials below) | (escriba las iniciales a continuación)*

Due to the coronavirus disease (COVID-19) pandemic, that is beyond our control, Bright Island Outreach is taking extra precautionary measures with the intake of each participant based on practices recommended by public health officials and related organizations. With that in mind, please read this carefully before accepting. THIS IS A RELEASE OF LIABILITY AND A WAIVER OF CERTAIN LEGAL RIGHTS. BY SIGNING BELOW, YOU ARE ACKNOWLEDGING AND ACCEPTING THE FOLLOWING: I consent to having my temperatures taken by a representative of Bright island Outreach upon entering any area of operation and to any other precautionary measures taken by Bright Island Outreach in striving to reduce potential exposure to COVID-19. I acknowledge and understand that Bright Island Outreach and it's representatives cannot guarantee that any precautionary measures taken by Bright Island Outreach will fully protect anyone from being exposed to and/or contracting COVID-19 or any other contagion. I understand the symptoms of COVID-19 include, but are not limited to: • Fever • Fatigue • Cough • Shortness of breath I affirm that I, each Participant, and all of our household members do not currently have any of the above symptoms and have not experienced any of the above symptoms within the last fourteen (14) days. In the event that I, any Participant, or any of our household members experiences any of the above symptoms after I sign this release, I agree that none of us will enter any Bright Island Outreach location until fourteen (14) days have elapsed since such person has experienced such symptom(s). I affirm that I, each Participant, and all of our household members have not been diagnosed with COVID-19 within the last thirty (30) days and have not been knowingly exposed to anyone diagnosed with COVID-19 within the last thirty (30) days. In the event that I, any Participant, or any of our household members is diagnosed with COVID-19 or is knowingly exposed to anyone diagnosed with COVID-19 after I sign this release, I agree that none of us will enter any Bright Island Outreach location until thirty (30) days have elapsed since such diagnosis or exposure. I affirm that I, any Participant, and all of our household members have not traveled to any location outside of my city of residence that is or has been considered a “hot spot” for COVID-19 infections within the last fourteen (14) days. In the event that I, any Participant, or any of our household members travels to any such location after I sign this release, I agree that none of us will enter any Bright Island Outreach location until fourteen (14) days have elapsed since such person(s) traveled to such location. Accordingly, I, individually and on behalf of each Participant, agree to each statement above and I also hereby waive, release, indemnify, and forever hold harmless Bright Island Outreach and affiliates, and their respective owner(s), directors, officers, agents, employees, representatives, successors and assigns, administrators, and executors, as well as any location at which any Bright Island Outreach Program is conducted and each of their respective owner(s), directors, officers, agents, employees, representatives, successors and assigns, administrators, and executors (collectively, the “Released Parties”) from all liabilities and claims for any injuries, losses, death, damages, or costs (including reasonable attorneys’ and experts’ fees) to myself, any Participant, my spouse, child, guests, unborn child(ren), or relatives which arise out of or are incident to any Participant’s participation in any activities relating to the Bright Island Outreach Programs provided by any Bright Island Outreach location or my attendance at any activities relating to the program provided by any Bright Island Outreach program location including those caused by any negligent act or omission by any of the Released Parties, by anyone at or using any facility at which any Bright Island Outreach program is conducted, or as a result of a defective product. This provision will apply to ordinary acts of negligence but will not apply to gross acts/omissions of negligence, willful, or wanton acts/omissions, or those of an intentional/criminal nature.

In the event travel to the Dominican Republic is restricted, the organizers reserve the right to postpone and reschedule the mission.

ASSUMPTION OF RISKS (type initials below) | ASUNCIÓN DE RIESGOS (escriba las iniciales a continuación)*

I acknowledge that travel to, from and within any foreign country contains risks and potential losses and I assume all responsibility for myself and accompanying family members during my trip. Therefore, I release Dr. Eric Harris, and other expedition coordinators from any liability or damages. | Reconozco que viajar hacia, desde y dentro de cualquier país extranjero contiene riesgos y pérdidas potenciales, y asumo toda la responsabilidad por mí y por los miembros de mi familia durante mi viaje. Por lo tanto, libero al Dr. Eric Harris y a otros coordinadores de expedición de cualquier responsabilidad o daños.

PHOTOGRAPHY/ VIDEO /UPDATES CONSENT (type initials below)*

I grant permission to Dr. Eric Harris and other participants or representatives to take photographs and video of me and to use, edit, publish and reproduce all images and videos of me for promotional and marketing purposes, fundraising, and other publications or presentations sponsored by Dr. Eric Harris or his affiliates, without restriction and without compensation to me. I release Dr. Harris from all claims and liability with respect to any photographs or videos of me that they take, use, edit, publish, or reproduce.

ACKNOWLEDGEMENT OF UNDERSTANDING (type initials below) | RECONOCIMIENTO DE ENTENDIMIENTO (escriba las iniciales a continuación)*

I have read this agreement, fully understand its terms, and I understand that I am giving up substantial rights, including my right to sue. I acknowledge that I am signing this agreement freely and voluntarily, and intend this agreement by my signature to be a complete and unconditional release of all liability of BRIGHT ISLAND OUTREACH. | He leído este acuerdo, entiendo completamente sus términos y entiendo que estoy renunciando a derechos sustanciales, incluido mi derecho a demandar. Reconozco que estoy firmando este acuerdo de forma libre y voluntaria, y pretendo que este acuerdo con mi firma sea una liberación completa e incondicional de toda responsabilidad de BRIGHT ISLAND OUTREACH.

Please type full name | Por favor escriba el nombre completo*

First Last

Signature

Date | Fecha*

Liability Waiver and Assumption of Risk

As you travel abroad, you are representing your family, your school, your community, and your country. The key to a successful trip is your open-mindedness and willingness to accept new cultures and the occasional inconveniences of international travel. If you keep your eyes and your mind open, you will bring home something of lasting value.
The purpose of Bright Island Outreach is to attend to the needs of global communities that have little or no access to oral health care while providing health care professional school candidates with opportunities to experience and contribute to communities in need. It is in this spirit that we make this assumption of risk agreement for this trip.
Event Description: Humanitarian Trip in Dominican Republic

Personal Responsibility (type initials below) | Responsabilidad personal (escriba las iniciales a continuación)*

I (undersigned name) understand that my participation in the 2025 Dominican Republic Humanitarian Expedition is subject to all of the following conditions, promises, agreements, and understandings. By signing this Release and Assumption of Risk Agreement, I understand that I am (1) agreeing to all of the following conditions and agreements; (2) making the stated promises; and (3) have the following understandings. I am solely responsible and liable for (1) obtaining all personal documentation appropriate for this trip including but not limited to, international passports and other forms of government issued identification; (2) paying all costs and expenses related to my participation in the program; (3) I am responsible for my punctuality, personal conduct, and personal belongings while traveling and (4) that the program is not responsible for the products or services provided by the host organization or the proper performance or presentation of their duties, obligations, products or services. | (Nombre abajo firmante) entiendo que mi participación en la Expedición Humanitaria de República Dominicana 2025 está sujeta a todas las siguientes condiciones, promesas, acuerdos y entendimientos. Al firmar este Acuerdo de exención y asunción de riesgos, entiendo que (1) estoy de acuerdo con todas las siguientes condiciones y acuerdos; (2) hacer las promesas establecidas; y (3) tienen los siguientes entendimientos. Soy el único responsable de (1) obtener toda la documentación personal apropiada para este viaje, incluidos, entre otros, pasaportes internacionales y otras formas de identificación emitidas por el gobierno; (2) pagar todos los costos y gastos relacionados con mi participación en el programa; (3) Soy responsable de mi puntualidad, conducta personal y pertenencias personales mientras viajo y (4) que el programa no es responsable de los productos o servicios proporcionados por la organización anfitriona o del desempeño o presentación adecuada de sus deberes, obligaciones, Productos o servicios.

Student Conduct Code (type initials below) | Código de conducta del estudiante (escriba las iniciales a continuación)*

I acknowledge that I have been advised regarding the Student Conduct Code associated with my affiliated educational institution and agree to abide by that code while participating in the program/trip. Further, I agree and pledge that I will comply with all regulations and directions given me by staff members while participating in the program, including University officials, volunteers and employees of the host organizations, and all other officials acting within their official capacities. I agree that I will comply with all applicable laws of the jurisdictions in which I travel and will not engage in any conduct or behavior that causes potential harm to myself or others, or is disruptive to the trip, the sponsoring organization, the educational institution, or the organization hosting our stay. | Reconozco que me han informado sobre el Código de Conducta del Estudiante asociado con mi institución educativa afiliada y acepto cumplir ese código mientras participo en el programa / viaje. Además, estoy de acuerdo y prometo que cumpliré con todas las regulaciones e instrucciones que me dieron los miembros del personal mientras participo en el programa, incluidos los funcionarios de la Universidad, los voluntarios y los empleados de las organizaciones anfitrionas, y todos los demás funcionarios que actúan dentro de sus capacidades oficiales. Acepto cumplir con todas las leyes aplicables de las jurisdicciones en las que viajo y no participaré en ninguna conducta o comportamiento que pueda causarme daño a mí mismo o a otros, o que sea perjudicial para el viaje, la organización patrocinadora, la institución educativa, o la organización que aloja nuestra estadía.

Damages Waiver (type initials below) | Exención de daños (escriba las iniciales a continuación)*

In consideration of approval for my personal attendance at the above-mentioned activity, I, for myself, my heirs, executors, administrators, and assigns, do waive, release, and discharge any and all rights, demands, or claims for damage and cause of suit or action known or unknown, that I may have against the State of Arizona, the affiliated educational institution, the sponsoring organization or their employees or agents for any or all injuries in any manner resulting from the above referenced class. I hereby authorize the event manager or their designee to request medical assistance as they find necessary and further attest and verify that I have full knowledge of all risks involved in this activity and that I will assume and pay my own medical and emergency expenses in the event of accident or illness regardless of whether I’ve authorized such payments.| En consideración a la aprobación de mi asistencia personal a la actividad mencionada anteriormente, yo mismo, mis herederos, ejecutores, administradores y cesionarios, renuncio, libero y descargo todos y cada uno de los derechos, demandas o reclamos por daños y causas. de demanda o acción conocida o desconocida, que pueda tener contra el Estado de Arizona, la institución educativa afiliada, la organización patrocinadora o sus empleados o agentes por cualquiera o todas las lesiones de cualquier manera que resulten de la clase mencionada anteriormente. Por la presente, autorizo al administrador del evento o su designado a solicitar asistencia médica cuando lo consideren necesario y atestigüe y verifique que tengo pleno conocimiento de todos los riesgos involucrados en esta actividad y que asumiré y pagaré mis propios gastos médicos y de emergencia en el evento de accidente o enfermedad, independientemente de si he autorizado dichos pagos.

Participation Termination (type initials below) | Terminación de la participación (escriba las iniciales a continuación)*

I understand and agree that the sponsoring organization and its affiliates shall have the right to enforce appropriate standards of conduct, and that they may at any time terminate my participation in the program/trip for failure to maintain these standards OR for any actions or conduct which the sponsoring organization considers to be incompatible with the interests, harmony, comfort, and/or welfare of the program and other participants. If my participation is terminated, I understand that I will be sent back at my own expense and with NO refund of any fees or costs. | Entiendo y acepto que la organización patrocinadora y sus afiliados tendrán el derecho de hacer cumplir los estándares de conducta apropiados, y que en cualquier momento pueden terminar mi participación en el programa / viaje por no mantener estos estándares O por cualquier acción o conducta que la organización patrocinadora considera que es incompatible con los intereses, la armonía, la comodidad y / o el bienestar del programa y otros participantes. Si se termina mi participación, entiendo que se me enviará de vuelta a mi propio costo y SIN reembolso de ninguna tarifa o costo.

Medical Treatment (type initials AND select below) | Tratamiento médico (escriba iniciales Y seleccione a continuación)*

I AGREE, REPRESENT, and CONSENT that in the event of any medical emergency I do / do not (select one below) authorize and consent to any x-ray examination, anesthetic, medical, dental, or surgical diagnosis, treatment or hospital care that Bright Island Outreach and/or its affiliates (including the organization advisor, program director, participating officials, or agents) deem necessary for my safety, health, or protection, and I FULLY RELEASE each of them from any liability for such decisions or actions taken in this regard. This consent includes, without limitation, an authorization to place me in a hospital for medical services or treatment or in the care of a local medical doctor. I certify that to my knowledge I have no medical conditions that would adversely affect my participation in the program. | ACEPTO, REPRESENTO y CONSENTIMIENTO que, en caso de cualquier emergencia médica, autorizo / no (seleccione uno a continuación) autorizo y consiento cualquier examen de rayos X, anestesia, diagnóstico médico, dental o quirúrgico, tratamiento o atención hospitalaria que Bright Island Outreach y / o sus afiliados (incluido el asesor de la organización, el director del programa, los funcionarios participantes o los agentes) consideran necesarios para mi seguridad, salud o protección, y LIBERO TOTALMENTE a cada uno de ellos de cualquier responsabilidad por tales decisiones o acciones tomadas a este respecto. Este consentimiento incluye, sin limitación, una autorización para colocarme en un hospital para servicios o tratamiento médico o al cuidado de un médico local. Certifico que, a mi entender, no tengo afecciones médicas que afecten negativamente mi participación en el programa.

Medical Treatment (please select one) | Tratamiento médico (seleccione uno)*

I DO consent | Doy mi consentimiento

I DO NOT consent | NO doy mi consentimiento

Program Itinerary (type initials below) | Itinerario del Programa (escriba las iniciales a continuación)*

Bright Island Outreach reserves the right to modify and/or change the Program Itinerary without notice. Every reasonable effort will be employed to operate the Program as planned; however, should unforeseen events and conditions require the itinerary to be altered or cancelled, BIO reserves the right to do so for the safety and best interest of the group. If these issues occur and BIO is forced to cancel a Program, BIO will attempt to rebook the Participant to an alternate program, subject to conditions and availability, and Force Majeure Terms and Conditions will apply. | Bright Island Outreach se reserva el derecho de modificar y/o cambiar el itinerario del programa sin previo aviso. Se emplearán todos los esfuerzos razonables para operar el Programa según lo planeado; Sin embargo, si eventos y condiciones imprevistos requieren que se modifique o cancele el itinerario, BIO se reserva el derecho de hacerlo por la seguridad y el mejor interés del grupo. Si ocurren estos problemas y BIO se ve obligado a cancelar un Programa, BIO intentará volver a reservar al Participante en un programa alternativo, sujeto a condiciones y disponibilidad, y se aplicarán los Términos y Condiciones de Fuerza Mayor.

Refunds (type initials below) | Reembolsos (escriba las iniciales a continuación)*

I understand that the sponsoring organization reserves the right to make changes in cases of emergency or changed conditions or in the interest of the group. Any refunds necessarily prompted by any such actions will be determined in each individual case at the sole discretion of the sponsoring organization. | Entiendo que la organización patrocinadora se reserva el derecho de hacer cambios en casos de emergencia o condiciones cambiadas o en interés del grupo. Cualquier reembolso provocado necesariamente por tales acciones se determinará en cada caso individual a la sola discreción de la organización patrocinadora.

Printed Full Name | Nombre completo*

Signature

Date

@BrightIslandOutreach

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