Global Experience Certificate

application form

 

Forms – International Volunteer Experience Risk Management Form

All fields must be completed as directed.

Student Information
(8 digits)

Student Responsibility

You must check each box to indicate you understand and accept responsibility for the following tasks. Failure to comply with this agreement will result in the GEC International Volunteer Experience not being approved for credit toward the GEC Certificate.

Immigration Authorization

     

OR

     

     





Health Coverage

All UW students must be covered by a provincial health care plan. This provides coverage for physician and hospital expenses up to the varied maxima of these plans. In addition, all UW students are required to participate in the FEDS/GSA Health & Dental Plan of the University of Waterloo which includes up to 150 consecutive calendar days of out-of-Canada coverage. Students however, can declare equivalent coverage and opt out of the FEDS/GSA Health & Dental Plan.



     

Are you on the FEDS/GSA Health and Dental Plan?

        

If you are not on the FEDS Health & Dental Plan, please provide the following:

Name of Insurer:
Policy Number:

By submitting this form, I indicate that I have checked my "out of Canada" coverage under the FEDS/GSA Health & Dental Plan of the University or an equivalent plan and consider it to be appropriate for the risks I know I will be facing.





For my personal security, I will:







Mandatory Pre-Release Orientation
Travel
         




Personal Information

You must ensure your emergency contact has copies of your personal information including passport, OHIP number, medical/travel insurance coverage, blood type and any information such as allergies, drug sensitivities, regular medications and other information (e.g. medical condition) that might be of significance to the University, a physician or hospital treating you in any emergency situation.

Student guarantees that medical insurance is in force for the duration of volunteering abroad, and in the case of an emergency, consents to the release of personal information as appropriate.


Emergency Contact

Provide the name and address of a designated person who can be reached on your behalf in an emergency.

By submitting this application, I am: