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					                            OKLAHOMA COOPERATIVE EXTENSION SERVICE
                                     Division of Agricultural Sciences and Natural Resources
                                           4-H Youth Development Program
                                        205 4-H Youth Development Bldg, Stillwater, OK 74078
                                                (405) 744-5390 (405)744-6522 – fax



                                                                                    October 26, 2009
Greetings,

I would like to thank you for your interest in assisting children in desperate need. 4-H is embarking on a new
journey by partnering with Feed the Children (FTC) in developing an International 4-H program/Study Abroad
Course that serves those overseas.

4-H is not directly affiliated with FTC or any religious organization or set, and as such, no endorsement is given
beyond the educational opportunities provided for you through this partnership.

We have two options from which you can choose. OSU policy requires we give you the opportunity to book your
own flight and travel itinerary. Or, Feed the Children will book your flight and make all the necessary
arrangements. If you wish to make you own travel plans you will be expected to meet us at the Nicaraguan airport
at the pre-arranged time to begin your adventure with us.

Included in with this letter is our current Project description. We will be traveling July 10-17, leaving out of
Oklahoma City to Houston to Managua, Nicaragua.

Please mail your completed application and deposit of $100 by March 1st to:
(Make checks payable to 4-H Conferences)

Oklahoma 4-H Youth Development
C/O Jeff Sallee
205 4-H Youth Development
Stillwater, OK, 74078

Your initial deposit will confirm your intent to attend. If you want Feed the Children to make your travel
arrangements, it will also hold your airline ticket, ground transportation, room and board. If you wish to make
your own travel arrangements, your deposit will confirm all except the plane ticket.

Upon receipt of your initial deposit I will correspond with you concerning the remaining fees and payment
options. I am looking forward to hearing from you soon. If you have further questions, please call me at 405/744-
8885 or email jeff.sallee@okstate.edu. I am looking forward to working with you.

This is our initial correspondence. More information will be forthcoming.

Sincerely,


Jeff Sallee
Jeff Sallee Ph D
Assistant Professor / Extension Specialist
4-H Youth Development
P.S. Each participant is expected to purchase travel insurance. I have enclosed the Forms used by FTC, OSU has
options. Insurance is purchased directly through the insurance company, not through OSU or FTC. To travel you
must provide proof of travel insurance.



                     Please review the following pages for more information.
                                                       CURRENT PROJECT
PROJECT LOCATION
Nicaragua

PROJECT DESCRIPTIONS
Teams will complete the restoration and build the buildings that will provide shelter, food, and other necessities for children. We will
be working on establishing a garden at the Feed the Children project location to help supplement the food supply and provide fresh
vegetables. Our hope is the project will serve as a demonstration garden for the surrounding community and serve as an example of
how the local population can feed itself. In addition to working on the garden project we may be expected to participate with the
mission group and may be asked to help with any of the following tasks.

         DEVELOPING POSITIVE RELATIONSHIPS WITH STAFF AS WELL AS CHILDREN IN THE SURROUNDING
          COMMUNITY
         CONSTRUCTING FEEDING CENTERS
         CONSTRUCTING HOMES FOR CHILDREN
         INSTALLING NEW ROOFING SYSTEMS
         CLEANING AND PAINTING
         INSTALLING ELECTRICAL AND PLUMBING FIXTURES
         LANDSCAPING AROUND LIVING QUARTERS
         DEVELOPING GARDENING PROJECTS
         PROVIDING FACILITIES FOR VOCATIONAL TRAINING

PROJECT NEEDS
According to UNICEF, 100 million children are homeless, living on the streets in constant struggle for survival. Many of these
CHILDREN sleep wherever they can find a place to lay their heads and eat whatever they can find, often digging through garbage for
something to sustain them. Many often turn to prostitution to survive.

As a result of the AIDS epidemic, children are orphaned or abandoned by parents and families who can no longer care for them. Feed
The Children projects will provide a safe place to meet the physical, medical, spiritual, emotional, educational and vocational needs of
children, until they can reenter the community as responsible and secure individuals.

Together, we can make a difference!

                                                     TRAVEL DATE FOR 2010

                                                           July 8-16, 2010
                                                       El Crucero, Nicaragua

        I also plan to arrange an educational day at OSU to give you a good background in gardening and help us plan our
                             Nicaraguan garden project. Once confirmed our project will be extended.

TENTATIVE COSTS
$575.00 per person plus airfare, Nicaragua (7 nights/ 8 days). The $575 includes ground travel, lodging, meals, team
shirt, taxes, and fees. Airfare through Feed the Children will cost approximately $850.00. Additional training time at
OSU $100.00 for a total trip cost of $1525.00. This price may vary due to airline costs. If we are not booking your flight
your total trip cost is 675.00.

Tuition will cost $150.00 per credit hour (3) for a total of $450.00 plus any additional fees.

Tentative Costs
Ground travel, lodging, meals etc.           625.00
Airfare from FTC                             900.00 (Estimated)
Total Est. Travel Costs                    $1525.00

Tuition                                    Estimated $180.00 per hour/ 3 credit hours $540.00
                           APPLICATION INTERNATIONAL 4-H PROJECT
The following questions will assist you in the application process. I will notify you, when the application
process is complete.

Please type or print clearly.

PART ONE

Date/Location of Project:       Nicaragua, July 9-16, 2010                                               _

Full Name:                                                                                               _
                                           (as is/or will appear on your passport)

Present Address:                                                                                         _

City:                                                        State: ______           Zip:                _

Home:                                      Work:                             Cell: ____________________

Email:                                              ___________________________________________

Present Occupation:

Date of Birth:         ______________________               Sex (circle one):        Male /     Female

Shirt Size (circle one): S      M      L       XL        XXL

Passport #:                                                 Expiration Date:_____

Country of Origin:

Marital Status: (Circle one):              Single         Married           Separated         Divorced

Since:           /     /            Spouse’s name:          ___

Do you want to book your airfare through Feed the Children                              Yes       No



PART TWO
Describe your reason for applying for this project:


Have you participated in a similar project? If yes, which country and organization?


Do you speak a language other than English? If yes, which one(s)?
Do you have other skills? (music, drama, art, teaching, etc.)



Do you have experience in building/construction work?

PART THREE
Circle your current state of health:

Physical:   Excellent/Good/Fair/Poor      Emotional: Excellent/Good/Fair/Poor

Have you recently been hospitalized for a physical or emotional condition?______________

If yes, explain briefly:



Are you currently receiving counseling?____________________________________________

Do you have any allergies, illnesses, or chronic conditions of which your team leader needs to be
informed? If yes, explain briefly and include any prescription medications you are taking for such
conditions: ________________



Special dietary needs:




PART FOUR

Please give the name, address and phone numbers of someone to whom you are accountable, and who
may be contacted by your team leader and asked to give a character reference. This person can be your
County Educator, 4-H Club Volunteer, Pastor or other mentor.

Name:

Address:

Phone: Daytime:                                  Evening:

        PLEASE INDICATE WITH AN “X” IN THE BOX, THAT YOU HAVE READ, UNDERSTAND,
        AGREE TO, AND WILL MAIL YOUR, SIGNED TERMS AND CONDITIONS FORM THAT IS
        ATTACHED TO THIS APPLICATION, TO THE FEED THE CHILDREN ADDRESS LISTED
        ON THE NEXT PAGE.



REFERENCE FORM
Name of applicant

Project Date(s) and Location(s) ____________________________________________________

Thank you for your help in giving us an understanding of this applicant. Please return the completed form, in a
sealed envelope, to the applicant. Please read the questions below and check the answers that best describe the
applicant.

HEALTH:        □ excellent    □ average      □ poor
INITIATIVE: □ develops original ideas        □ average       □ depends upon others
CONCERN FOR OTHERS: □ strong                 □ average       □ self-oriented
LEADERSHIP ABILITY:           □ very apparent         □ average       □ follower
ABILITY TO FOLLOW:            □ good         □ average       □ poor
MENTAL ABILITY: □ quick in comprehension              □ average       □ slow
INDUSTRY: □ hard worker                □ average      □ lacks tenacity
RELIABILTIY:          □ meets obligations □ average          □ neglects obligations
CO-OPERATIVENESS: □ works well with others □ average □ prefers to work alone

DISPOSITION:          □ cheerful       □ average      □ depressed
SOCIAL ATTITUDE:              □ teachable    □ average       □ unyielding character
ADAPTABILITY:         □ flexible, makes good judgments       □ average         □ needs work
DRESS:         □ neat □ average        □ sloppy
SPEECH:        □ careful      □ average      □ loose
Would you be pleased to have this person as a fellow worker?          Explain:



If there is anything else you think we should know about this applicant, please use the reverse side of this paper
to tell us. Again, thank you for your help.

Your name:                                                                     Date:

Phone:
Feed the Children has high expectations of their mission trip participants. Our
 4-H group/class will be traveling with church members from Arkansas and
   Illinois. The total group size will be about 30 participants. If you are not
 comfortable agreeing to the following terms and conditions you will want to
           consider a different study abroad or 4-H trip opportunity.

                                    TERMS AND CONDITIONS
      Each member is expected to be an active participant in all phases of the project. .
      Team members shall not enter into a romantic relationship throughout the duration of the project.
      Each member is expected to perform any and all task(s) assigned, which include setting up and cleaning
       up the site.
      Schedules and time lines are critical to the smooth flow of the project. Tardiness cannot be allowed.
       Only Team Directors or Team Leaders can change the schedule.
      Use of alcoholic beverages or tobacco products is not permitted.
      DRESS CODE: Due to customs and cultural beliefs in host countries, a dress code is necessary.
       Suggested attire: Jeans, overalls, slacks, dresses, skirts with shirts or blouses. If dressed inappropriately,
       you will be asked to change before arriving at the work site.
      Behavior, actions and dress considered acceptable in the United States might be misunderstood or
       misconstrued by citizens of the host country. If you have any doubt about propriety, please ask ahead to
       avoid embarrassment to all.
      In instances of conflict, please communicate with the parties involved and team leaders immediately in
       order to bring about speedy resolution.
      Team members are asked to demonstrate kindness and understanding to other team members and the
       people of our host country.
      The final decision for acceptance will be made by, Feed The Children, Inc., and John and Catherine
       Ware in conjunction with the Pastor, Team Leader, or Mission Board/Committee of the applicant’s
       church.

Deviation from these guidelines could seriously hinder the work of missionaries in our host countries. For this
reason, Feed The Children encourages prayerful consideration before you commit to the Team’s mission.
Failure to follow guidelines could result in an early return to the United States at your own expense. The
individual cost for a Short-Term Mission trip including airfare, hotel, and meals will be at your expense and is
tax deductible. A valid passport is required.

I agree to abide by these guidelines and rules of conduct, if selected for a Short-Term Mission Project.


Signature of participant                              Signature of spouse (if married)


Date                                                  Signature of witness (if unmarried)


                                                      Date
                                                          RELEASE
I,________________________________________________________________________, am participating in a:

                                   Construction Team                   Key Pastors

                                  __________________               ________________
                                     please initial                   please initial

         Acknowledgement of Risk, I understand and acknowledge that the activity I am about to voluntarily engage in as a
         participant or as a volunteer bears certain risks, known or unknown, identified or unidentified, anticipated or
         unanticipated, which may result in injury, death, illness, disease (physical or mental) or damage to myself, my
         property or to spectators or to other third parties.

    1.   Acceptance of Risks and Responsibility, Being aware that this activity entails risks or injury to myself and a risk or
         injury to spectators or other third parties as a result of my actions, I expressly agree, covenant and promise to accept
         and assume all responsibility and risks for injury, death, illness or disease or damage to myself or to my property
         arising out of my participation in this activity. I expressly agree, covenant and promise to accept and assume all
         responsibility and risk of injury, death, illness or disease, or damage to spectators or other third parties and their
         property arising from my participation in this activity. My participation in this activity is purely voluntary and no
         one is forcing me to participate, and I elect to participate knowing said risks.

    2.   Release, I hereby voluntarily release and forever discharge Feed The Children, Inc., its successors and assigns, agents,
         employees, directors, officers and all other persons or entities from any and all liability, claims, demands, action or
         rights of action which are related to or arise out of or are in any way connected with my participation in this activity
         including, but not limited to, the negligent acts or omissions of Feed The Children, Inc., its successors and assigns,
         agents, employees, directors, officers and all other persons or entities, for any and all injury, death, illness or disease,
         and damage to myself or to my property. I further agree, promise and covenant to hold harmless and indemnify Feed
         The Children, Inc., its successors and assigns, agents, employees, directors, officers and all other persons or entities,
         from all defense costs, including attorney fees or from other costs incurred in connection with claims for bodily injury
         or damage which I may negligently or intentionally cause to myself, to spectators or other third parties arising from
         my participation in this event.

    3.   Acknowledgement and Effect of This Release Agreement, I understand and acknowledge that by initialing and signing
         this document, I have given up certain legal rights and/or possible claims which I might otherwise assert or maintain
         against Feed The Children, Inc., its officers, directors, assigns, agents or other employees and persons or entities. I
         understand and acknowledge that by initialing and signing this document I have assumed responsibility and legal
         liability for the claims or other legal demands including defense costs which may be asserted by spectators or other
         third parties against me as a result of my participation in this event.

My signature below indicates that I have read this entire document and completely understand it and agree to be bound by
its terms. I am at least eighteen (18) years of age, or have had my parent or guardian sign this Release on my behalf.


_______________________________________                       ____________________________________________
Participant                  Date                             Parent or Guardian                     Date

In case of emergency, please contact:

Next of Kin____________________________________               Relationship____________________________________

Address_____________________________________________________________________________________
              Street Address                      City                    State              Zip

Telephone Number(         )_________________________
  Emergency Information Check List:
TEAM MEMBER INFORMATION

        Team Members Name _________________________________________________________________
        Phone number (Home) _______________________________(Office)___________________________
        (Cell)_________________________________________ (Fax)_________________________________
        Email_______________________________________________________________________________

     IN THE EVENT OF AN EMERGENCY PLEASE CONTACT THE PERSON BELOW:

        Name ______________________________________________________________________________
        Address_____________________________________________________________________________
        Contact Phone ______________________________ Alternate Phone : __________________________

  Do you have a history of serious illnesses, allergies or any special medical needs?

  Specify:
  __________________________________________________________________________________________
  __________________________________________________________________________________________
  __________________________________________________________________________________________


        Please bring a photocopy of your passport– and carry it separately from your passport.
        Please give a photo copy of your passport to your team leader.
        Please keep copy of detailed flight itinerary.
        Please carry emergency information and immunization record on your person at all times.
        Please give a copy of the emergency information and immunization record to your team leader.


  Financial Arrangements:
  Feed The Children will provide as much information as possible concerning the finances of your trip ahead of
  time. Estimated cost for the trip will include air transportation, land transportation, lodging, departure taxes,
  tips, food, extra baggage, sightseeing and tourist information. Passports, visas (if required), insurance,
  immunizations, souvenirs and gifts are extra.

  Team Member signature:       ____________________________________ Date_________
                                (Please sign, indicating you have read above paragraph)
                         General Information from Feed the Children
WE ARE BUILDERS FOR CHILDREN (BFC), PART OF THE SHORT-TERM MISSIONS DEPARTMENT
AT FEED THE CHILDREN, SPECIALIZING IN VOLUNTEER CONSTRUCTION TEAMS. WE WILL BE
GLAD TO HELP YOU WITH TIPS ON RAISING FINANCIAL SUPPORT FOR YOUR TRIP.
INVOLVING OTHERS IN RAISING FUNDS, NOT ONLY HELPS YOU, BUT WILL ALSO PROVIDE
YOUR SUPPORTERS WITH AN ACTIVE ROLE IN CHANGING THE LIVES OF CHILDREN. ALL
CONTRIBUTIONS ARE TAX-DEDUCTIBLE.

INFORMATION ON THE COST OF BFC MISSION TRIPS ARE AS FOLLOWS:

   1. CENTRAL AMERICA TRIPS: 7-9 DAYS
      COST: APPROXIMATELY $1600 (Will fluctuate with airfare and fuel prices)

       SUB-SAHARA AFRICA TRIPS: 14 DAYS
       COST: APPROXIMATELY $3600 (Will fluctuate with airfare and fuel prices)

   3. YOU MUST HAVE A VALID PASSPORT. IF YOU DO NOT HAVE A VALID PASSPORT,
      CHECK WITH YOUR LOCAL COURTHOUSE IMMEDIATELY. YOUR PASSPORT MUST
      BE CURRENT UNTIL, AT LEAST, SIX MONTHS AFTER YOUR RETURN DATE WITH
      BUILDERS FOR CHILDREN.

We calculate the cost of each trip as follows:


        Central America Trips are $625.00 for hotel, ground transportation, meals, tips, taxes and team shirt,
        etc. plus airfare.


        Africa Trips are $1200.00 or hotel, ground transportation, meals, tips, taxes and team shirt, etc. plus
        airfare.


        Passports and Insurance are extra.


IT NORMALLY TAKES SIX WEEKS TO OBTAIN A PASSPORT. PLEASE CONTACT OUR OFFICE, AT
888-210-7734, FOR INFORMATION ON HOW TO OBTAIN YOUR PASSPORT QUICKLY.


NOTE:
IF YOU ARE 17 OR YOUNGER YOU MUST BE ACCOMPANIED BY YOUR PARENT OR GUARDIAN.
PLEASE CHECK WITH YOUR PHYSICIAN ABOUT IMMUNIZATIONS NEEDED FOR YOUR TRIP.
               IMPORTANT
             INFORMATION!
All team members are required to purchase travel insurance two
weeks before trip departure.

This is an additional fee that is not included in the cost of your trip
with Feed The Children. Customs Assurance Placements, Ltd. has
given all team members a special rate of $2.85 per day insurance
coverage. You will need to calculate the number of days you will be
traveling times $2.85 to come up with the amount to send along with
your application to Customs Assurance Placements, Ltd.


Make your check payable to Customs
Assurance Placements, LTD. and mail it
immediately with your application to:
Customs Assurance Placements, Ltd.
Attn: Tracy Simmons
A Specialty Lines Insurance Broker
PO Box 5736, Columbia, SC 29250-5736
Tel: (803) 799-1770 Fax: (803) 799-1817 Toll Free: (888) 799-1770 ext 105
E-mail: tsimons@customassurance.com


You will receive confirmation in the mail
from Customs Assurance Placements, Ltd.
once your insurance application is
processed.
             Charity Assurance Travel Insurance
 Information for Volunteers/Employees and Project Leaders of International Not for Profit
                                    Organizations

Please give this your attention as you consider the needs of those volunteers/employees who make a
commitment to help in your field of service.

Many Not for Profit sending organizations have been struggling with the need to have a valid
TRAVEL INSURANCE PROGRAM for the volunteers/employees going out to the field.

Large numbers of persons are now traveling from one to four weeks to engage in relief work,
construction, medical, and other tasks. The number of serious accidents being experienced present
some real concerns.

The travel insurance issued by a travel agent on a ticket does not cover the traveler while engaged in
work on the field.

When a period of disability occurs as a result of someone falling off a roof, or experiencing a sport or
automobile accident, the Volunteer -- and often the sending organization -- cannot afford to help the
person financially over a period of disability.

Some sending organizations suggest that all travelers take out the TRAVEL INSURANCE that
includes disability coverage. This gives peace of mind to the Volunteer/Employee and the sending
organization.

Coverage can be customized to suit the organizations specific needs and has a minimal daily cost.
This coverage has been used by over 50,000 volunteers annually and is recommended by those you
have benefited by it in a time of crisis.

Individuals and groups can enroll in the program by using the attached sheet -- or by contacting:


                              Customs Assurance Placements, Ltd.
                               A Specialty Lines Insurance Broker
                             PO Box 5736, Columbia, SC 29250-5736
            Tel: (803) 799-1770 Fax: (803) 799-1817 Toll Free: (888) 799-1770 ext 105
                               E-mail: tsimons@customassurance.com
                Charity Assurance Travel Insurance
Due to numerous inquiries we have had from our clients, Adams & Associates International has developed a package of insurance
benefits specifically designed for Volunteers/Employees of Not for Profit Organizations.

      Summary of                           Accidental Death & Dismemberment ...................................... $100,000.00/Person
                                           Disability Income Benefit for Permanent Total Disability
      Coverages
                                           For Accident 100 Month Benefit ................................................... $1,000.00/Month

                                           For Sickness 50 Month Benefit
                                           3 Month Waiting Period ................................................................... $250.00/Month
                                           Medical Expense $100.00 Deductible ..................................................... $2,500.00

                                           *OPTION to INCREASE LIMIT to ......................................................... $10,000.00
                                                                             This additional $7,500.00 applies to
                                                                     Non-USA & Canada Medical Expenses ONLY
                                           Emergency Medical Transportation ...................................................... $50,000.00
                                           Repatriation of Mortal Remains ............................................................... $7,500.00
                                           Medical Assistance (24 Hour Telephone Service)
                                           For Assistance with Worldwide Medical Emergencies .............................. Included
                                           Property (Baggage) Insurance
                                           $100.00 Deductible ................................................................................. $2,500.00
                                           Aggregate Limit ................................................................................ $2,000,000.00
                                           Please Note: This brief summary is not an insurance policy, rather, it outlines some of the
                                           features of this coverage. For specific details, please consult the Master Policy.

                                           Also Note: This is not a major medical policy. Major Medical Coverage is available for
                                           individuals and groups on short-term and long-term assignments. If this is a need specific
                                           to your group, please contact us for details.

           Notes                           1.          The Aggregate Limit of $2,000,000 provides the full $100,000 AD&D coverage
                                                       for up to 20 persons in a common accident. Higher limits up to $10,000,000
                                                       are available for groups of 20 or more       persons together and is included
                                                       automatically when the additional premium on the Enrollment for 21 persons or
                                                       more in the same            group is paid.
                                           2.          For persons age 70 or over and certain children, The Accidental Death &
                                                       Dismemberment Benefits are reduced to $10,000.00 and there is no Disability
             Rate                                      Income Benefit.

                                           $2.30 per person per day with a medical limit of $2,500 - or -

                                           *$2.85 per person per day with Optional "Overseas Only" medical coverage.
                                            (The entire group must enroll under the same plan).
       Enrollment
                                           To secure coverage, complete the form entitled Enrollment, and return it along with your
       Procedure                           check for the premium made payable to: Adams & Associates International. In computing
                                           the number of days, count the departure day as well as the day of return.

                                           If coverage is being secured for a group, the group would be responsible for
                                           requiring all Volunteers/Employees to carry this insurance. In the event the entire
                                           group is not traveling on the same dates, please attach a separate sheet grouping
                                           the Travelers by the dates they are traveling.
              American International Group (AIG ASSIST)
              Provided For Volunteers/Employees of Not for Profit Organizations
Adams & Associates International's plan provides comprehensive travel assistance while traveling and
serving overseas, by simply calling the telephone numbers provided.

These insurance benefits cover Travelers, who are covered by accidental death and dismemberment
insurance, while in transit and overseas.
                                   Medical Assistance can help the travelers get medical attention when
            Medical                someone suddenly becomes ill or is in an accident by:

         Assistance                           locating medical facilities, including physicians, hospitals,
                                               or dentists
                                              verifying insurance coverage
                                               making arrangements with providers of medical care to avoid cash
                                                deposit, where possible, prior to obtaining treatment
                                               communicating with family members, personal physicians, and
                                                employers back home on the patient's condition
                                               assisting family or friends who are traveling with the patient

                                   Emergency Medical Evacuation will make proper medical care available
         Emergency                 from anywhere:

            Medical                        Medical Advisers - are always on hand to consult with attending
                                           physicians to make sure patients are receiving the correct medical care.
         Evacuation                        But, sometimes more sophisticated treatment is warranted - treatment
                                           which may require evacuation to better medical facilities.

                                           If deemed medically necessary, arrangements will be made for land and
                                           air transportation, including passage on either a commercial or chartered
                                           air ambulance, with in-flight physicians, paramedics or nurses and in-
                                           flight equipment and supplies. All family arrangements and immigration
                                           and customs details will also be handled.

                                           Travel expenses associated with medical evacuation will be covered up
                                           to $50,000.00 under this program.

                                   Arrangements for repatriation of the remains of a deceased person will be made
       Repatriation                and up to $7,500.00 of the expense will be covered by this program. (Some
                                   countries forbid the shipping of the deceased.)

                                   Legal Assistance provides a ready resource for travelers helping to find English-
              Legal                speaking attorneys for persons in danger of being arrested as the result of any
                                   non-criminal action, or needing to replace lost or stolen documents, such as
         Assistance                passports, or personal items, such as luggage.


To use these services, contact American International Group (AIG INTERNATIONAL SERVICES) and identify
that you are with Not for Profit Volunteers, ID #902-7994-A

                                       Call Houston, Texas:
                                 24 Hour Service         or      Call Collect
                                 1-800-626-2427                 713-267-2525
 Charity Assurance Travel Insurance Enrollment
Please make photocopies of this                        Check One:
form for use on future trips.                             Group Leader              Travel Agent           Individual

Please Print
Name:
Signature:                                                   Date:
Address:
City:                                             State:                                                   Zip:
Phone:                                  Fax:                    E-Mail:
Sponsoring Organization or Other Group:
Master Policy Number:          NOT FOR PROFIT VOLUNTEERS #902-7994-A
                       City:                                 Country:
Destination:

Expected Date of Departure from Home:
Expected Date of Arrival Back Home:

Please note, this is not a major medical policy. Major Medical Coverage is available for individuals and groups on
short-term and long-term assignments. If this is a need specific to your group, please contact us for details.
Premium Computation

Standard:   _____________________ X ___________________ = ________________ X 2.30 =
______________
                   Number of Persons             Number of Days              Person/Days                          Premium
W/Optional: _____________________ X ___________________ = ________________ X 2.85 =
______________
                   Number of Persons             Number of Days              Person/Days                          Premium
                                 WHOLE GROUP MUST SELECT THE SAME PLAN
                   Additional Charge of $2.50 Per Person for Groups of 21 Persons or More ONLY.

          21 Persons or More:       ______________________          X    2.50   =    _____________________
                                        Number of Persons                                     Premium



List of Persons
                      Name                                 Date of Birth                           Beneficiary
1.
2.
3.

If several persons are participating in a single project, but for different dates of service, please list these persons showing
their dates separately, married couples traveling together should list both husband and wife. Travel agents or Group
Leaders may attach roster in lieu of completing this list.

Mail or Fax to:                  Customs Assurance Placements, Ltd.
                                  A Specialty Lines Insurance Broker
                                PO Box 5736, Columbia, SC 29250-5736
               Tel: (803) 799-1770 Fax: (803) 799-1817 Toll Free: (888) 799-1770 ext 105
                                  E-mail: tsimons@customassurance.com
                                          AIG Life Insurance Company Trust
                                                   PARTICIPATION AGREEMENT
                                                                                                    For Policy Number ___902-7994-A______

THIS AGREEMENT, made and entered into as of the _____day of ______, 20___, by and between Crestar Bank and
_________________________________.
                                                        RECITALS

          1. Crestar Bank has been appointed and is acting as the Trustee under an Agreement of Trust dated January 1, 1986, titled the
AIG Insurance Company Trust (the "Agreement of Trust"), by and between AIG Life Insurance Company and Crestar Bank, hereinafter with
any other trustee or trustees serving under the Agreement of Trust referred to as the "Trustee"). The purpose of the Agreement of Trust is
to afford group insurance benefits to qualifying persons, members, customers or employees of certain organizations.

          2. ____________________(hereinafter, with any successor or successors thereto, referred to as the "Participant") desires to
afford to qualifying insureds group insurance benefits of the sort available under the Agreement of Trust.

           NOW, THEREFORE, in consideration of the mutual promises herein contained, the Trustee and the Participant hereby agree as
follows:

         1.        Subject to approval of the insurance company or companies providing the group insurance pursuant to which insurance
benefits shall be provided (the "Insurance Policies") for any insureds of the Participant, the Trustee agrees to permit the Participant to
become a Participant under the Agreement of Trust.

         2.       The Participant agrees to be bound by: (a) the provisions of the Agreement of Trust, and (b) each and every provision of
the Insurance Policies (and all riders and amendments thereto). The definitions contained in the Agreement of Trust shall apply in the
construction and interpretation of this Participation Agreement.

          3.       In particular, but without the generality of the foregoing, the Participant agrees promptly to furnish to the Trustee and the
insurance company or, if requested by the Administrator under the Agreement of Trust to do so, to the Administrator, all records and other
information required by the insurance company to administer properly the Insurance Policies and to permit the Trustee, the insurance
company and/or the Administrator, whenever and as often as the Trustee, the insurance company and/or the Administrator may reasonably
require, to inspect the records of the Participant bearing on the Insurance Policies.

         4.         The Participant hereby appoints the Administrator (if any) acting under the Agreement of Trust to represent the
Participant in all dealings with the Trustee having to do with the insurance fund, including, by way of example and not of limitation of the
foregoing, such matters as instructions to the Trustee, the resignation or dismissal of the Trustee and the appointment of a successor or
successors, amendment of the Agreement of Trust, the fixing and adjustment of the Trustee's fee and all other matters pertaining to the
construction of the Agreement of Trust, its effect and the administration of the insurance fund.

         5.       In the event that the Participant shall withdraw as a Participant under the Agreement of Trust in accordance with the
provisions thereof, the Participant agrees that it shall relinquish any and all claims the Participant may have on the date on which such
withdrawal becomes effective, or which thereafter may accrue, to any portion of the insurance fund.

          6.       The Trustee shall make available at its principal place of business and during normal business hours, upon reasonable
notice to the Participant or any one or more of the qualifying persons, members, customers or employees of the Participant an executed
original counterpart of the Agreement of Trust and all amendments thereto which shall at the time be in force and effect.

         7.         The Participant shall pay, when due, the cost of all group insurance applicable to the Participant's qualifying persons,
members, customers or employees by means of a check or checks payable to the Trustee or its designee. Payment in any other manner
shall be at the risk of the Participant.

          IN WITNESS WHEREOF, on the day and year first above written, the parties hereto have caused these presents to be executed
by their respective officers thereunto duly authorized.

Accepted on behalf of Trustee:
                                                                      PARTICIPANT:____________________________________________

Custom Assurance Placements, Ltd.                                     ________________________________________________________


By: ________________________________________________                  *By: _____________________________________________________
                    Administrator

				
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