Duluti Optima Volunteer & Student Exchange Program Duluti Optima Volunteer & Student Exchange Program Application Form Application FormSection 1: Personal InformationFullnameGender Male Female Prefer not to sayPassport NumberEmailDate of BirthNationalitySelect NationalityAfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelauBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicDemocratic Republic of the Congo (Kinshasa)DenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRepublic of the Congo (Brazzaville)ReunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (Dutch part)Saint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia/Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited Kingdom (UK)United States (US)United States (US) Minor Outlying IslandsUnited States (US) Virgin IslandsUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabwePassport Expiry DatePhone/MobileCurrent AddressApplicant AddressCityZip CodeCountryAfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelauBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicDemocratic Republic of the Congo (Kinshasa)DenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRepublic of the Congo (Brazzaville)ReunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (Dutch part)Saint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia/Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited Kingdom (UK)United States (US)United States (US) Minor Outlying IslandsUnited States (US) Virgin IslandsUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabwePreviousNextSection 2: Academic InformationAcademic InstitutionCurrent Year of Study Ist Year 2nd Year 3rd Year Postgraduate Professional VolunteerHave you ever been enrolled in an overseas elective or clerkship Yes NoDegree ProgramField of StudySection 3: Program PreferencesWhich Program are you Applying for? Pre-Clinical Rotations / Placements Clinical Clerkship Research collaboration Professionals/Volunteers (More than 3 months) Trauma-Surgery Dissection Course for Resource-Limited &Conflict Settings Community and Rural Hospital RotationsPreferred Destination(s) in TanzaniaDo you require accommodation assistance? Yes NoDo you require assistance with transportation (airport transfer, local transport)? Yes NoPreferred Dates for Program ParticipationStart DateEnd DateField of Interest (research, clinical, etc.)PreviousNextSection 4: Supporting Documents Please attach the following documents to your application (PDF or JPEG formats):Copy of PassportChoose File Proof of Enrollment (from your academic institution) Choose File Consent and Declaration DateCurriculum Vitae (CV)Choose File Motivation LetterChoose File Attach Signature HereChoose File I have read and understood the terms and conditions of the Duluti Optima Volunteer & Student Exchange Program. I hereby consent to the collection and use of my personal data for the purposes of program administration. I confirm that the information provided is true and accurate to the best of my knowledge. I have read and understood the Code of Conduct of the Duluti Optima Volunteer & Student Exchange Program.I hereby consent to follow all protocols.PreviousNextHealth Declaration FormSection 1: Personal InformationFullnameEmailDate of BirthPhone/MobileSection 2: Medical HistoryDo you have any pre-existing medical conditions? Yes NoIf yes, please provide detailsDo you have any allergies (including food, medication, Bee sting etc.)? Yes NoIf yes, please specifyAre you currently taking any prescription medication? Yes NoIf yes, please list the medicationsDo you have any mobility issues or physical limitations? Yes NoIf yes, please explainSection 3: Emergency InformationNamePhone/MobileRelationship to ApplicantEmail AddressSection 4: Medical InsuranceDo you agree to obtain a valid health/travel insurance that covers medical treatment before arriving to Tanzania Yes No I declare that the information provided in this health declaration is accurate to the best of my knowledge. I understand that failure to disclose any relevant medical information may affect my participation in the program and agree to provide any necessary updates to this information before travel.SignatureChoose File Health Declaration DatePreviousNextLiability WaiverSection 1: Participant InformationNameEmail AddressDatePhone/Mobile I, the undersigned, understand and acknowledge that participation in the Duluti Optima Volunteer & Student Exchange Program may involve inherent risks, including but not limited to health risks, transportation risks, and cultural differences that may affect my experience. I voluntarily assume all risks associated with my participation in the program. I, the undersigned, hereby release and hold harmless Duluti Optima, its staff, partners, and affiliates from any claims, damages, or liabilities arising from injury, loss, or damage to person or property during my participation in the program, except where caused by gross negligence or willful misconduct. I give consent for medical treatment in the event of illness or injury during my participation in the program. I understand that I am responsible for any medical costs incurred that are not covered by my insurance. I have read and fully understand this waiver and release. I am voluntarily signing it with full knowledge of its content and legal consequences.Upload SignatureChoose File Date Previous Submit Application