SUMMER INTERFAITH CHESED PROGRAM APPLICATION

INSTRUCTIONS:

1. Please print, complete, sign and return the application forms to: CDPA, 203 Rockingstone Ave. Larchmont, NY 10538. 914-833-7787. CDPA@cdpa-americas.org. (Personal Information, Code of Ethics, Release Form)
2. Include a non-refundable application fee check of $400.00. Make checks payable to: Community Development Partners for the Americas, LLC.
3. Include a short essay telling us about yourself and the reasons you have chosen to join a Summer Interfaith Chesed program.
4. Include three photocopies of the first page of the traveler’s passport
5. Include a copy of your health insurance card, back and front.

APPLICATION FOR PARTICIPATION IN INTERFAITH CHESED '07

PART 1: PERSONAL INFORMATION

Full Name:
Date of Birth:
Gender:
Social Security Number:
School:
Home Address:
City: State: Zip code: Country:
Home Phone: Cellular Phone :
Students email:
Father’s email
Mother’s email
School Phone and name of Guidance Counselor
Country of Residence:
Place of Birth:
Citizenship:
Passport Number :
Passport Expiration Date:
Health Insurance Carrier:
Name of Insured:
Policy Number:
Father’s Name:
Mother’s Name:
Parents address and phone number (if different from permanent above):

Emergency Contact Name:
Phone Number:
Email address:

Please provide us with a brief explanation as to special circumstances or concerns: (special diets, health issues, disabilities, etc.). Please describe in detail. All information is strictly confidential and it will be used solely for the purpose of arranging for special services as needed.



➢ Previous international travel:
➢ Do you know Spanish? Hebrew? Other?
➢ Need Special Diets?
➢ Taking Medications?
➢ Allergies?
➢ Health Issues?
➢ Disabilities?

PART 2: FINANCIAL INFORMATION

Method of payment: Check, Money Order, Cash, Partial Credit Card payments allowed. Total Cost: The tuition for the entire Chesed Program is $4,757.00 only all inclusive. Make checks payable to: Community Development Partners For the Americas, LLC. 203 Rockingstone Avenue. Larchmont, NY 10538. 914-439-7731.


PART 3: ADDITIONAL INSTRUCTIONS

Total Cost: The tuition for the entire Interfaith Summer Chesed Program is $4,757.00 only. The tuition includes international round trip air fare (from NY), all lodging, three daily meals and snacks, all special meals, all domestic air and ground transfers, all entrance fees, all cultural, social and touring activities, all program related activities, all social and entertainment events and materials. Price does not include airport taxes. (presently $18.00 airport tax payable at departure from Argentina)

Deadline: Last date for receipt of applications is March 18, 2007. Full payment must be received by that date. After that date, depending on availability, tuition will be $4,957.00

Cancellations: Depending on airline, hotels, buses and other supplier’s policies. After receipt of application a voucher for your deposit will be issued and e-mailed.

Please Make all checks payable to: COMMUNITY DEVELOPMENT PARTNERS FOR THE AMERICAS, LLC. 203 Rockingstone Avenue. Larchmont, NY 10538, USA. Tel: 914-833-7787 / 914-439-7731. Email: CDPA@cdpa-americas.org.

PART 4: CODE OF ETHICS:

Code of Ethics and Behavior. Please fill in your name in the spaces provided.

• I, ,the participant in the trip to Argentina, July 18-August, 19 2007, agree to abide by the code of conduct of the sponsoring organization, CDPA, and the code of conduct of the school in which I am pupil. I agree that any deviation from this code of conduct will result in my immediate dismissal from the program. I agree that dismissal for reasons of conduct will result in possible damages to CDPA and that the return to my country of origin will be at my parent’s exclusive and sole expense. I agree that the well being of the group as a whole will be the paramount consideration that will guide my behavior during the trip. In the event of a dispute, final arbitration of conduct will solely rest with the sponsors.

• I, ,understand and agree that during the course of the trip, I will not be allowed to use alcohol, tobacco products, any illegal drugs, or generally behave in any way unbecoming a member of the Interfaith Chesed program. I understand that failure to comply will result in my immediate expulsion form the program at my parents exclusive and full expense.

• Travelers are required to consult with their Medical Doctors concerning any issues related to immunizations, medications to take to the trip or other personal health concerns. Travelers are required to submit in writing ahead of the trip any requests for special medical services. Travelers are required to disclose to the organizers any special disabilities, diet requirements or psychological concerns so as to be able to arrange in advance for the provision of special services as required. Failure to comply with these requirements will result in potential damages to the travelers, the group and CDPA. please initial here:

I read the application and the code of conduct and liability and agree to abide by its requirements.

Name of traveler:
Signature: Date:


Father’s name: Mother’s name:
Signature: Signature:
Date: Date:


PART 5: WAIVER AND RELEASE:

Release executed on the___day of __________ , 200 __ , by ________________ (the 'Traveler Releasor') , resident of__________________________________________to CDPA (the 'Releasee').

I, the Releasor, in consideration of being permitted to participate in the Interfaith Chesed Trip to Argentina, scheduled for July 18, 2007 - August 19, 2007, and run and/or operated by the Releasee, waive, release, and discharge the Releasee, its owners, officers, directors, employees, members, agents, assigns, legal representatives and successors, and all business associates and partners involved in the presentation of the above noted activity and each of them their owners, officers and employees, and any other people officially connected with this event from all liability for or by reason of any damage, loss or injury to person and property, even injury resulting in the death of the Releasor, which has been or may be sustained in consequence of the Releasor's participation in the activity described above, and notwithstanding that such damage, loss or injury may have been caused solely or partly by the negligence of the Releasee. I am aware of the risks of participation. I understand that participation in this program is strictly voluntary and I freely chose to participate. I understand that the Releasee does not provide medical coverage for me. I verify that I will be responsible for any medical costs I incur as a result of my participation


Date:
Name of Traveler:
Name of Parent:
Name of Parent:


Signature of Traveler
Signature of Parent
Signature of Parent



Brief Bio:

Dr. Hune Margulies is the Director of The Martin Buber Institute for Dialogical Ecology. Hune is the founder of CDPA, Community Development Partners for the Americas, an organization engaged in cultural preservation, environmental awareness, community formation and cooperative economic programs within Indigenous and working class regions of Latin America. For a number of years, Hune served as a Deputy Commissioner in the Division of Housing and Community Renewal in the State of New York. As a component program of his work in Latin America, Hune organizes and conducts study tours to Indigenous communities and to ecological sites throughout the continent. Hune recieved a Ph.D. from Columbia University, an MA in Philosophy from Fordham University and an MA from Hunter College. Hune is writing a book on the Philosophy and Principles of Dialogical Ecology. (http://buber-zen-the-between.blogspot.com, http://westchesterhavurah.blogspot.com). Hune is married to Dr. marian Wiener-Margulies, a licensed child Psychologist and has three children, Amos, Hadas and Isaiah.