Expedition Application Step 1 of 5 20% Name* First Last Phone*Email* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Gender*MaleFemaleDate of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Age* Employment & Volunteer ExperiencePlease briefly describe your past employment and/or volunteer experience.EducationPlease briefly describe your education experience and any certifications you may hold.Skills, Talents, & GiftsDo you have any skills, talents, or gifts you would like to share with Rising Star Outreach?International Travel ExperiencePlease briefly describe your international travel experience (if any), especially if you have traveled in Asia.Have you ever been convicted of a crime?* Yes No Criminal History*Please give brief details including dates, convictions, outcome, and follow-up.Social Media & BloggingWill you (or would you like to) share your volunteer experience online? Select all that apply: Yes! I have a blog and would love to share my experience online. Yes! I post on social media regularly and want to share my experience and pictures online. Maybe. I am not tech savvy, but I might like to share my experience on the Rising Star blog. No. I am not interested in sharing my experience with others online Your Website/Blog address: Which apps do you use to share?Please select all that apply: Facebook Instagram Twitter Pinterest Your Facebook page or username:Your Instagram username:Your Twitter username:Your Pinterest username: MedicationAre you taking any medications (including inhalants) or receiving any medical treatments? If yes, please provide a brief summary of any medication you are currently taking:Previous Injury & Other Medical ConditionsHave you had any serious injuries, illness, surgeries, etc? If yes, please provide brief details, including dates, treatment, outcomes, and if you are currently receiving treatment.Anxiety, Depression, etc.Have you ever are or you currently seeing a counselor, psychiatrist, or medical doctor for any psychiatric or psychological issues, including anxiety or depression? If yes, please give brief details including dates, medication, treatment, outcome, and if you are receiving any current treatment.Allergies?Do you have any allergies? If yes, please list all allergies that affect you, and how you treat them.Insurance*Are you currently insured? Please check all that apply: Health Vision Dental Life Traveler's No, none of these Emergency Contact*Who should we contact in the event of an emergency? First Last Relation*What is this person's relation to you? Emergency Contact's Phone Number*Emergency Contact's Email Reference No. 1*Please list two referrals with their appropriate contact information and relation to you. Reference No. 1: First Last PhoneReference No. 2* First Last Phone Expedition Preferences*Please indicate your preference for which expedition(s) that you would like to attend. Check all that apply: Women to Women 1: Jan 7th-13th Women to Women 2: Jan. 21st-29th Women to Women 3: Feb. 18th-24th Private Family Session: Feb. 25th-Feb. 28th Spring Break 1 March: 11th-16th Spring Break 2 March: 18th-23rd Spring Break 3 March: 25th-30th Summer Expedition 1: June 10th-18th Summer Expedition 2: June 24th-July 2nd Summer Expedition 3: July 8th-16th Summer Expedition 4: July 22nd-Aug. 1st Summer Expedition 5: Aug. 5th-11th Summer Expedition 6: August 19th-29th Thanksgiving Expedition: November 18th-23rd December Expedition: December 16th-21st Flexibility*There's always a chance that your preferred expedition may have filled up by the time we process your application. If that is the case, are your dates flexible?Yes! If the session I selected fills up, please let me know what else is available.No, this is the only time I'm available. Please put me on a waiting list in case things open up.How did you hear about Rising Star Outreach?PhoneThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.