* Last Name:
* First Name:
* Email:
* Sex:
Male Female
* Date of Birth:
Month
January February March April May June July August September October November December
/
Day
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
/
Place of Birth:
* Nationality
USA Canada Afghanistan Albania Algeria Andorra Angola Antigua & Barbuda Argentina Armenia Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bhutan Bolivia Bosnia & Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Cape Verde Central African Republic Chad Chile China, Peoples Republic of Colombia Comoros Congo, Democratic Republic of Congo, Republic of Costa Rica Côte d Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Fiji Finland France Gabon Gambia Georgia Germany Ghana Greece Grenada Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea (North) Korea (South) Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mexico Micronesia, Federated States of Moldova Monaco Mongolia Montenegro Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Zealand Nicaragua Niger Nigeria Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Qatar Romania Russia Rwanda Saint Kitts & Nevis Saint Lucia Saint Vincent & the Grenadines Samoa San Marino São Tomé & Príncipe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa Spain Sri Lanka Sudan Suriname Swaziland Sweden Switzerland Syria Tajikistan Tanzania Thailand Taiwan Timor-Leste Togo Tonga Trinidad & Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United Kingdom Uruguay Uzbekistan Vanuatu Venezuela Vietnam Yemen Zambia Zimbabwe Other
Passport Number:
Profession:
Agricultural Architect Art & Design Business College Student Community & Social Services Computer & Technology Dental Doctor Education Engineers & Construction Entertainers & Performers Entrepreneur Graduate Student - Other Healthcare - Other High School Student Legal Mathematician MBA Student Media & Communications Non-profit Nursing Pre-dental & Dental Student Pre-med & Medical Student Retired Person Scientist Stay at Home Parent Other
Do you have a promotion code? Enter here (optional):
* Did someone refer you to United Planet?
Yes No
* Destination:
Cambodia Chile China Summer Costa Rica Ecuador Ghana Guatemala Honduras India Italy Japan Jordan Mexico Nepal Peru Romania South Africa Tanzania Tibet USA
* Project:
Women's Empowerment Teaching Construction Healthcare Environmental Orphanage Animals/Wildlife Other
Please indicate your preference, and note that not all projects are available at all times. Your project placement will be confirmed after your phone session with your coordinator in the Boston Office. Thank you!
* Expected Arrival Date:
Month
January February March April May June July August September October November December
/
Day
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
/
Year
2012 2013 2014 2015 2016 2017 2018 2019 2020 2021
* Expected Departure Date:
Month
January February March April May June July August September October November December
/
Day
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
/
Year
2012 2013 2014 2015 2016 2017 2018 2019 2020 2021
Quest duration:
1 week 10 days 2 weeks 3 weeks 4 weeks 5 weeks 6 weeks 7 weeks 8 weeks 9 weeks 10 weeks 11 weeks 12 weeks
Are you in school?
Yes No
The next few questions will help us find the perfect project for you. Please indicate if you have special education, skills, or interests. Thanks!
Please describe your educational background and any relevant work experience :
Please include any languages that you speak and how
fluent you are at speaking this language:
Please describe your strengths and weaknesses, interests and hobbies, and any volunteer experience or intercultural experience you have had:
Would you be willing to talk with future Quest volunteers upon your return to share your experiences or take part in other United Planet activities and programs?
Yes No
Preferred method of communication:
Phone Email Both
Do you have any objections to sharing a room?
Yes No
Do you smoke?
Yes No
(for host family placement)
Do you have any special dietary requirements?
No Vegetarian Other
Do you have any allergies?
Yes No
* How did you hear about us?
Search Engine Friends/Family Magazine/Newspaper TV/Radio Book Email Mail On campus VolunteerAbroad.com TransitionsAbroad.com Idealist.org Other website UP Representative Student Universe Conference/Event Google Ads Facebook Ads Facebook Community Amazon Ads Other
Please specify how you heard about United Planet. Be specific if possible.
Please list 1-3 names of local and/or community newspapers in your hometown.
* Contact person in case of emergency (name, address, telephone, e-mail)
* Beneficiary for Travel insurance (name, address, telephone, e-mail).
Please let us know the name and email of the person who introduced you to the Quest program. (optional) (Each
person providing a referral will receive a 10% discount on the Quest program)
What is your T-shirt size?
Small Medium Large X-Large
* Have you been convicted of a felony?
Yes No
* Within the past five (5) years have you been convicted of, or completed a period of incarceration for, a misdemeanor which was not a first conviction for drunkenness, simple assault, speeding, a minor traffic violation, an affray, or disturbing the peace?
Yes No
Please Note:
1. Conviction of a crime or a guilty plea to a criminal charge will not necessarily disqualify an applicant. United Planet will consider the gravity of the offense, the time passed since conviction or plea and the nature of the volunteer position sought.
2. An applicant with a sealed record on file with the commissioner of probation may answer 'no record' with respect to an inquiry herein relative to prior arrests, criminal court appearances or convictions. In addition, any applicant may answer 'no record' with respect to any inquiry relative to prior arrests, court appearances and adjudications in all cases of delinquency or as a child in need of services that did not result in a complaint transferred to the superior court for criminal prosecution.
*
I certify that the above information is true, complete, and correct to the best of my knowledge. I represent that I have withheld nothing which, if disclosed, would affect this application unfavorably. I understand that any false statement, misrepresentation or omission made by me on my application, resume, or any other materials I have submitted, or during my interviews, can result in denial of my application, or, if I have already been accepted as participant in a Quest when such false statement, misrepresentation or omission is discovered, immediate termination of my participation in the Quest. I understand that, if my participation in the Quest is terminated under such circumstances, I will not be entitled to any refund of the Quest fees that I have paid to United Planet, nor will anyone else who has paid such fees on my behalf be entitled to any refund.