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Fields marked with an * are required Name and affiliation of group, if applicable Number of people participating in this one week project Number of adult males Number of adult females Your First Name Your Last Name Date of Birth Address 1 City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Country Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua And Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia And Herzegowina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo, The Democratic Republic Of The Cook Islands Costa Rica Cote D'Ivoire Croatia (Local Name: Hrvatska) Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Timor-Leste (East Timor) Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France France, Metropolitan French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard And Mc Donald Islands Holy See (Vatican City State) Honduras Hong Kong Hungary Iceland India Indonesia Iran (Islamic Republic Of) Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea, Democratic People's Republic Of Korea, Republic Of Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Luxembourg Macau Macedonia, Former Yugoslav Republic Of Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia, Federated States Of Moldova, Republic Of Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint Kitts And Nevis Saint Lucia Saint Vincent And The Grenadines Samoa San Marino Sao Tome And Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia (Slovak Republic) Slovenia Solomon Islands Somalia South Africa South Georgia, South Sandwich Islands South Sudan Spain Sri Lanka St. Helena St. Pierre And Miquelon Sudan Suriname Svalbard And Jan Mayen Islands Swaziland Sweden Switzerland Syrian Arab Republic Taiwan Tajikistan Tanzania, United Republic Of Thailand Togo Tokelau Tonga Trinidad And Tobago Tunisia Turkey Turkmenistan Turks And Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Venezuela Viet Nam Virgin Islands (British) Virgin Islands (U.S.) Wallis And Futuna Islands Western Sahara Yemen Yugoslavia Zambia Zimbabwe Zip / Post Code Email Phone Occupation (and specialized fields if applicable) Languages Spoken Gender MaleFemale Arrival Date Start Date Departure Date Name and State of school attending (if applicable) How did you find out about us? Emergency contact. Provide all physical, postal and email addresses and phone numbers of a family member who is responsible in the case of a medical emergency. Please list any medications you currently take. Please detail any relevant medical, mental, or emotional history such as serious operations, conditions, depression, allergies, migraines, back problems, or anything else that might be relevant to your service in Belize, to international travel, or to an emergency situation anywhere. Provide any background information of participant qualifications, skills, or experience that might be relevant to the project. Explain any goals or achievements you hope to accomplish through this project. Please list your educational experience Please list your work history, including volunteer work. Give an example of a project that you have initiated and carried out to the end (can be at work, volunteer, etc.) Describe a situation in which you demonstrated your ability to work as a part of a team. Explain what you feel are important aspect of teamwork and how you see yourself contributing to a positive team environment. Some of Cornerstone's on-site facilities can house up to 12 people with a shared bathroom and kitchen. Describe how you think you would relate to others and what role you would take in this type of living situation. List some of the ways in which you deal with stressful situations. Describe and previous experiences in Belize and any current relationships with people you know in Belize. Describe any other previous intercultural experiences. Explain why you wish to volunteer at Cornerstone. List your skills, hobbies, and interests (especially those which you may be relevant to the program area you have chosen) Please choose a Cornerstone program area (Women, Health, Youth, HIV/AIDS, Relief and Aid, Literacy) and explain how you think your skills, experience, and talents could contribute to that program. If you are interested in more than one program area, please list them in order of preference with your top choice being first. Please choose a Cornerstone work area (Fundraising, Website development, Volunteer recruitment, Office work) and explain how you think your skills, experience, and talents could contribute successfully to this line of work. If you are interested in more than one area, please list them in order of preference with you top choice being first. Please explain how you think your skills, experience, and talents could contribute successfully to this line of work. Do you want to take Spanish classes as part of this program? YesNo To volunteer at Cornerstone travel health insurance is required. Your insurance must include: 1. emergency medical evacuation, and 2. at least $15,000 in advance payment to a hospital if needed to secure your admission to the hospital as the result of an injury or sickness. You can purchase insurance for as little as $50 to $300. STA Insurance is an option open to you that meets Cornerstone's requirements.Your insurance papers must be presented during orientation. Yes, I understand that I must have required travelers insurance for the time I am at Cornerstone *