2008 / 2009 Rustic Pathways Gap Year Application
Please fill out all of the information below and then click on "Submit Your Application."
 (*Applications received after May 1, 2008 will need to pay a $100 application fee.)


Part 1:  Personal Data 

Name (Middle) (Last)
Country of Citizenship (s)
Place of Birth
Gender
Date of Birth
Passport Country of Issue
Passport Expiration Date


Current Address (where you would like to receive mailings)

Street  
City State  Zip
   
Country Home Phone
Cell Phone Email

Permanent Address (if different from above)

Street  
City State  Zip
   
Country Phone

Mother/Guardian
Name (First) (Middle) (Last)
Address
   
City State Zip
Home Phone Cell Phone  
 
Email Fax  
 
Work Phone    
   

Father/Guardian

Name (First) (Middle) (Last)
Address    
   
City State Zip
Home Phone Cell Phone  
 
Email Fax  
 
Work Phone    
   


Part II: Selecting Your Program

I am selecting the ENTIRE Scheduled Gap Year Program, September 1, 2008- June 5, 2009
I am selecting PART of the Scheduled Gap Year Program

Peru
Costa Rica  
Fiji
Australia
New Zealand   
Thailand
Cambodia
Laos
India
China
South Africa and Tanzania

I am selecting the Gap For Good Program


The country (s) I am requesting to visit:

I am selecting the Custom Gap Year Option

  
Countries I want to visit are:

Flight Arrangements
**You are responsible for organizing your international air travel. Please arrive at the designated city in the specified date.

What is your intended start date for your trip and what city will you be departing from?
What is your intended return date and where will you be returning?

Are there any specific types of travel that you are looking to do? Check all that apply

Backcountry Trekking Language Classes Kayaking Heliskiing
Scubadiving Cooking Classes Skydiving Bungee Junping
Snowboarding Sandboarding Zorbing Hiking
Snorkling      

Part III  Getting to Know You

High School (s) Attended
Location Dates Attended
Location Dates Attended
Location Dates Attended
High School from which you graduated

Have You Studied Any Languages Other than English?


If yes, please describe your level of ability in each language and number of years of study

Please tell us briefly about your previous international travel experience

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Have you traveled with Rustic Pathways before? If so, what programs did you participate in and when did you travel with us?

What Travel experience has been the most rewarding or memorable in your life so far?

Where are you currently attending or planning to attend college?

Are you looking for academic credit for this experience?

Have you had experience with Community Service? If So, briefly describe your most meaningful involvements and your time commitments to each project:

Do you see community service as being part of your Gap Year? If so, How much community service would you like to incorporate into your plans?

If you have any specific types of community service plans in mind, please describe them here.

What are your goals for your Gap Year program? How do you expect to grow as a person during your Rustic Pathways experience?

 

Part IV

We are proud to meet a wide variety of medical needs and concerns. Please provide us with some of your medical information in order for us to plan the safest and most accommodating trip possible.


Do you have any allergies or dietary issues? Yes No
Do you smoke?  Yes No
Do you have asthma or any concerns in high altitudes?  Yes No
Do you have any medical condictions, chronic illnesses or injuries?  Yes No
Are you taking any long term prescription medications?  Yes No       Please list
Do you have any particular dietary practices (veganism, vegetarianism) that you would like to continue on your Gap Year? Yes No
We try our very best to accommodate all diets though it is easier in certain countries than others.  Please explain:
 


Part V Legal


Existence of criminal convictions/adjudication may not disqualify you from consideration. Please answer each question completely. Do not include traffic violations.


Have you even  been convicted, or adjudicated as a junenile offender, of any criminal offense by either a civilian or military court other than minor traffic violations?    Yes No
Are you now under charges for any offenses?   Yes No
Are you on probation or parole?   Yes No

If you answered yes to any of the following questions, please complete the following:


Date of incident

City
State
Charge

Action Taken

Court, Probation or Parole Officer’s Name
Telephone
City
State

REGARDING FLIGHT INFORMATION

AIRLINE TICKETS
Students on Gap Year Programs are allowed to arrange their own flights to our programs. You must arrive on the scheduled arrival day and time window otherwise you will incur a minimum of a $100 dollar fee. We can arrange your airfare for you at an extra cost, though sometimes our prices are cheaper because of our contacts with the airlines. We are also able to book refundable fares, unlike many websites. Keep in mind that if you book your flights with us, schedule changes DO occur and may impact your student’s flight. Rustic Pathways is not able to alter or transfer your son or daughter’s flight arrangements at any time.

THE TOTAL COST OF YOUR TRIP


The total cost of your trip is simply your $ 100 Application Fee, plus the cost of the trip or trips that you have selected, plus the cost of the airfare for your program. You are also responsible for any tax on your plane ticket, as well as departure taxes from the country or countries you visit. Our acceptance letter will provide a careful breakdown of your total trip cost. Spending money for souvenirs, film or other purchases is your responsibility.

Included in the cost of your trip is a free Rustic Pathways T-shirt!
Rustic Pathways gives every student one FREE 2008 Summer t-shirt. We ask you to wear our cool shirts whenever you are flying with Rustic Pathways or connecting between trips. Please check your t-shirt size below (these are men’s sizes) and we will send your free shirt with your airline tickets.

In the box below, indicate the size of your free t-shirt.

 
Size of free T-shirt (Check One) *
Youth L14-16 S M L XL XXL XXXL

Most students ask for 2 or 3 spare shirts to give as gifts, to use for signing nights, and to wear when their shirt gets funky. Each extra shirt is $ 15. Please order your additional shirts by indicating the number of each size below. We will send these with your airline tickets as well.
How many spare T-shirts do you want to order? Please select the number in the appropriate box!
S M L XL XXL XXXL

ABOUT THE RUSTIC PATHWAYS ORGANIZATION

Rustic Pathways (USA), Inc., (“Rustic Pathways”) is based in the State of Ohio. The company offers travel programs throughout Australia, Thailand, New Zealand, Costa Rica, The Fiji Islands, The South Pacific, Africa, India, Vietnam, and the world. Rustic Pathways offers adventure, community service, language, and educational programs for high school students, college students, groups, individuals, and families.


CHANGES TO DATES AND ITINERARIES

Rustic Pathways reserves the right to change, alter, or completely cancel a trip at any time. We will advise you when possible of any significant changes to airline schedules or internal touring scedules that may alter your trip. Aside from adjustments due to things such as closed roads and flight schedule changes, we rarely cancel or change significant aspects of our programs. If a particular program or session does not fill, Rustic Pathways reserves the right to offer an alternate trip or departure date prior to the beginning of your trip. If you are unable to accept an alternate date or program, Rustic Pathways will refund the money you have paid toward your trip, including your application fee. Our programs are very popular and it is rare for us to cancel a program. Your trip must be paid in full no later than 45 days prior to your departure.


INSURANCE

MEDICAL INSURANCE
Parents are responsible for medical coverage for the entire period that their son/daughter is traveling. Rustic Pathways does NOT provide ANY form of medical coverage for students on our trips. Participants and their parents are responsible for any costs incurred before, during, or after participation in a Rustic Pathways Gap Year Program regardless of cause. Particpiants are reaquired to provide documentation of overseas medical coverage for the duration of the program NO LATER than 45 days prior to the departure of the student. COVERAGE MUST INCLUDE EMERGENCY MEDICAL EVACUATION. Some parent’s insurance plans do provide overseas coverage. Please call your individual provider to find out details on student’s specific benefits. If you plan on having your son or daughter use their home insurance policy overseas, get an international contact number for your insurance provider and MAKE SURE THAT YOUR STUDENT HAS A COPY OF THEIR INSURANCE CARD.

TRAVEL INSURANCE
Rustic Pathways does not offer a travel or medical insurance program, nor are we affliated with any insurance programs. However, we have used travel insurance companies in the past and find them quite affective. Access America is a provider that many of our previous clients have used.


LIABILITY WAIVERS, RELEASES, MEDICAL DISCLOSURES & RULES

Both participants and their parents will be required to sign and comply with various liability waivers and releases prior to the beginning of any Rustic Pathways trip. Rustic Pathways operates various trips in diverse countries, terrain and conditions. Many Rustic Pathways trips include challenging components such as bungee jumping, sky diving, heli-skiing, paintballing, zorbing, river boarding, kayaking, boating, cycling, 4-wheel-driving, horseback riding, rafting, aircraft flight, rappelling, abseiling, mountain climbing, zip-lining, elephant riding, scuba diving, mountain biking, surfing, skiing, hiking, camping, game viewing, working with machinery and tools, snowboarding, and travel in remote areas, as well as other potentially dangerous activities. Neither Rustic Pathways nor its officers, directors, contractors, employees, agents or staff can safeguard against injuries or accidents which may occur for whatever reason on any trip. Participants will not be permitted to travel on any Rustic Pathways trip unless all required paperwork has been received in our Ohio office at least 30 days prior to the commencement of the applicant’s trip.


PASSPORTS, VISAS & IDENTIFICATION

All students require a valid passport. To be considered valid , it must be god for at LEAST SIX (6) months from your return date. Please make a black and white copy of your passport and send it along with your first payment. If you do not currently have a passport or it needs to be renewed, a mandatory copy is due to Rustic Pathways no less than 65 days prior than departure. STUDENTS ARE RESPONSIBLE FOR ARRANGING THEIR OWN VISAS


WHAT WE EXPECT FROM PARTICIPANTS

Rustic Pathways expects participants to be enthusiastic, cooperative and appreciative of the opportunities afforded to them through our programs. Trips sometimes operate under difficult and challenging conditions, and Rustic Pathways expects participants to be cooperative and attentive at all times. Rustic Pathways reserves the right to remove any student from any trip at any time without any refund if a student endangers the lives of other students, or consistently disregards staff instructions. Students who use drugs, possess an uncooperative attitude or are unwilling to work happily within a team environment should not apply for a Rustic Pathways program.

DRUGS and ALCOHOL
Use of drugs is illegal in all of the countries in which we operate. Punishment for possession or use is often much more severe than in the Unites States. While traveling with Rustic Pathways, students are subject to local laws and police action. The use of drugs is prohibited. Alcohol use is permitted in moderation by students over the age of eighteen. Abuse of alcohol or behavior resulting from the abuse of alcohol that puts the program or its participants at risk will result in immediate termination from the program without a refund.


IMPORTANT INFORMATION ABOUT TRIP PAYMENT AND TRIP CANCELLATION

The total cost of your trip is payable in equal monthly installments. Your first monthly payment is due 15 days after your acceptance date. Remaining payments are due monthly. Complete trip payment must be received 65 days prior to your scheduled departure. During the normal application period trip payments are spread out into equal monthly installments as this makes it easier for many families to afford a summer program for their children. The non-refundable Application Fee can be placed on your Visa or Mastercard, or paid by cash or check. All other trip payments must be paid either by check or cash and must be paid on or before their due date. All late payments will incur a $50 late payment charge.

Rustic Pathways reserves the right to cancel a student’s place or reservation on any program if payment is not made on time.


Student has read, understands and agrees to abide with the above statement.*
Parent/Guardian has read, understands and agrees to abide with the above statement.*
 


PLEASE READ CAREFULLY AND CHECK WHERE INDICATED

We would like to apply for admission to a Rustic Pathways program. We have read the Rustic Pathways brochure and application form carefully, and we willingly agree to comply with all of the various requirements and conditions spelled out in these materials. We understand that student travel can be dangerous and we agree to abide by the rules, conditions and instructions provided by Rustic Pathways to minimize the risk of injury, accident, damage, or death. We further understand that Rustic Pathways has the right to remove any applicant from any program at any time if their behavior or participation is deemed to be detrimental or dangerous to themselves or others. We also understand that we will be required to sign and comply with various written waivers, liability releases, and terms and conditions as a condition of participation in this program. We fully understand that the relationship between us and Rustic Pathways (USA), Inc., (“Rustic Pathways”), will be governed by the laws of the State of Ohio and any suit, mediation or arbitration of any dispute with Rustic Pathways must be filed exclusively in the State of Ohio. We have enclosed our Application Fee with this application. We understand Rustic Pathways will send a confirmation letter within 5 days of their receipt of this application.

IMPORTANT: Please be sure both applicant and parent/guardian complete of this application

Parent or Guardian agrees to these terms and  conditions*
 Date(mm/dd/yyyy)*
Applicant agrees to these terms and conditions *
 Date(mm/dd/yyyy) *