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T1WT Program Application

READ BEFORE COMPLETING THE APPLICATION: You're one step closer to Thailand! We remain so excited that you're interested in joining us, and we're looking forward to getting to know you better. Our application process is designed to ensure our travelers and programs are mutually well-suited. It is essential that you respond to each question honestly and disclose any medical and mental health conditions and/or behavioral and social concerns. We want to be able to support you, and we need complete information to determine how and if we are able. We will discuss your individual circumstances in more detail during the interview to ensure the traveler meets our Enrollment Eligibility Criteria for safe, happy, and healthy participation in the program. The application may be completed by either the traveler and/or their parents/guardians; however, we ask parents/guardians and travelers to prepare responses to the Short Answer sections separately. We encourage both parties to use these responses as starting points for discussions to begin preparing for the adventures ahead. **This form does not allow you to save and return and must therefore be completed in one sitting.** We recommend parents/guardians and travelers prepare their Short Answer responses in a separate document and then copy/paste into the spaces provided below. We have provided Google Doc links for both here. Please click the link and select "make a copy." Short Answer Questions for Travelers: https://docs.google.com/document/d/1AN8me10cau6c7S4_UiG8qOPDPc5LHS1_pZ79DPthV40/edit?usp=sharing Short Answer Questions for Parents/Guardians: https://docs.google.com/document/d/1pN6XY7sye94Rpf68kzi_5cD-cJ2b-lkk_uM_eOoF7Qw/edit?usp=sharing Note: You will need to submit a copy of the traveler's passport and proof of the traveler's vaccination for COVID-19 (i.e. vaccination card). Please have both ready before beginning the application. Please ensure the designated signature spot on the passport is signed by the traveler (even if they are under 18 years old).

TRAVELER INFORMATION
    Month / Day / Year (i.e. June 2, 2006 = 06/02/2006)
    Age on June 30, 2023
    Gender
    Preferred Pronouns
    Race
    Please select all that apply.
    • Asian
    • Black
    • Indian
    • Latinx
    • Middle Eastern
    • Native American
    • Pacific Islander
    • White
    • Other
    Include country code (i.e. +1 781-721-7334)
    Does traveler have WhatsApp?
    Include country code (i.e. +1 781-721-7334)
    Enter an email address traveler will use before, during, and after the program, so that important correspondence is not missed. Please don't use a school email address that will expire.
    Has traveler ever been away from home for more than 5 days?
    Has traveler ever attended a diabetes camp?
    Has traveler ever traveled outside of their home country?
    T-Shirt Size (Unisex)
    Photo of Traveler
    Please include a clear photo of traveler's face without sunglasses. If upload popup does not appear, please scroll down, upload, and then back up to continue.
    Attach file
    Drop files here
    HOME ADDRESS
      Can you accept packages at this address?
      Please write your address exactly as it should be written on a package (if different from above).
      • {name}
      PASSPORT INFORMATION
        Does traveler hold a current passport?
        EDUCATION INFORMATION
          Current School Year
          Would you be interested in T1WT programs for young adults? (College/university students, early 20's, etc.)
          DIABETES INFORMATION
            Type of Diabetes
            Month / Day / Year (i.e. April 10, 2009 = 04/10/2009)
            A1c Unit
            System Traveler Uses for Blood Glucose Monitoring
            When travelers in a group use different systems, we provide conversion charts to all group members.
            Preferred Diabetes Descriptor
            Has traveler ever had a severe low blood sugar (seizure, loss of consciousness, or other?)
            Does traveler recognize their symptoms of high/low blood sugar?
            What are traveler's most commonly presenting low blood sugar symptoms?
            • {name}
            Does traveler struggle with hypoglycemia anxiety (anxiety about low blood sugars/the possibility of going low)?
            Has traveler ever been in DKA?
            Has traveler ever demonstrated any risk-taking behavior in relation to diabetes, including but not limited to: intentionally omitting insulin, under bolusing or over bolusing, etc.?
            Has traveler ever struggled with diabulimia?
            Insulin Administration Method
            Can traveler administer their own injections?
            For MDI users: daily management. For pump users: in case of pump error or failure.
            Can traveler make their own insulin dosaging decisions?
            Can traveler reasonably estimate carbohydrate counts?
            Does traveler wear a Continuous Glucose Monitor (CGM)?
            Does traveler use a DIY system (i.e. Looping)?
            Please note: using a DIY system will NOT disqualify you from enrolling in T1WT programs.
            Is traveler currently participating in any clinical trials?
            I.e. Children's Hospital Chicago, Denver Diabetes Center, etc.
            Please include country code.
            Just a year
            Will this provider be able to complete medical clearance forms for SCUBA diving?
            Please let us know if you need these forms translated from English into another language below.
            Will you need SCUBA diving medical clearance forms translated to another language?
            NON-DIABETES HEALTH & MEDICAL INFORMATION
              Does traveler have any non-food-related allergies?
              Does traveler have any food-related allergies OR restrictions (intolerances, specific dietary needs)?
              Has traveler been hospitalized (including psychiatric facilities)?
              Please list any serious injuries and accidents (including type, date, and treatment) even if they did not require hospitalization.
              • {name}
              Does traveler take any medication aside from insulin?
              Does traveler currently have or have a history with...
                Acrophobia (Fear of Heights)
                Asthma
                ADD/ADHD
                Anxiety
                Claustrophobia
                Depression
                Eating Disorders
                Epilepsy
                Gastrointestinal Issues
                Learning or Developmental Disorders
                Migraines
                Motion Sickness
                Muscular-Skeletal Problems
                Sleeping Problems
                Substance Abuse
                Does traveler have any other medical or mental health conditions?
                Has traveler received counseling or therapy within the last two years?
                Is traveler currently attending counseling or therapy?
                Will counseling or therapy be necessary during the T1WT program dates?
                Please note: We are not able to accommodate teletherapy appointments on-program.
                Is traveler fully vaccinated for COVID-19?
                Please upload a copy of traveler's vaccine card (proof of vaccination).
                If upload popup does not appear, please scroll up, upload, and then back down to continue.
                Attach file
                Drop files here
                Overall, are there any concerns about traveler participating fully in activities such as swimming, rock climbing, hiking, biking, kayaking, SCUBA diving, etc.?
                Are there any concerns about traveler’s ability to self-manage their diabetes, allergies, and/or other medical and mental health conditions?
                Are there any concerns about traveler’s ability to contribute positively to a group travel experience?
                Use this space if needed to help us to understand the traveler’s difficulties with diabetes management, physical, emotional and psychological needs, behavioral problems, social concerns, possibility of homesickness, etc.
                Information provided will help us support the traveler to have a safe, happy, healthy, confidence-building, FUN T1WT experience.
                • {name}
                OTHER INFORMATION
                  Swimming Ability
                  Can traveler swim 8 lengths of swimming pool without aids?
                  Can traveler float on water for 10 minutes without aids?
                  PRIMARY PARENT/GUARDIAN'S CONTACT INFORMATION
                    Include country code i.e. +1 847-441-0232
                    Does primary parent/guardian have WhatsApp?
                    If not, please download.
                    If different from mobile phone number
                    Primary Parent/Guardian’s Relationship to Traveler
                    Does primary parent/guardian live in the same home as traveler?
                    SECONDARY PARENT/GUARDIAN’S CONTACT INFORMATION
                      Include country code.
                      Does secondary parent/guardian have WhatsApp?
                      If not, please have them download.
                      If different from mobile phone number
                      Secondary Parent/Guardian’s Relationship to Traveler
                      If "other," please describe the relationship between the secondary parent/guardian and the traveler.
                      • {name}
                      Does secondary parent/guardian live in the same home as traveler?
                      Important email correspondence is typically between traveler, their primary parent/guardian, and T1WT staff. Would you like correspondence CC'd to the secondary parent/guardian as well?
                      EMERGENCY CONTACTS
                      Please list two people we can contact in the event neither primary nor secondary parent/guardian can be reached during an emergency.
                        Include country code.
                        SHORT ANSWER QUESTIONS – TRAVELER
                        As a reminder, this form does not allow you to save and return and must therefore be completed in one sitting. We recommend parents/guardians and travelers to prepare their Short Answer responses in a separate document and then paste below. We have provided Google Doc links for both at the top of the page. Please click the link and either download or select "make a copy" to fill in your responses. Then, copy/paste into the spaces provided below.
                          Complete the following statements with a word or phrase:
                            (The top 3 countries I want to visit are...)
                            Respond to the following questions in 6-12 sentences.
                              Please spend some time reviewing the Core Values detailed on our website. Which 2 or 3 of our values resonate most with you? Why?
                              • {name}
                              What about participating in a Type 1 Way Ticket program do you think will be most challenging for you? How will you try to overcome those challenges?
                              • {name}
                              Share a time when you navigated a conflict, faced a challenge, or questioned a belief. How did you react or respond? What did you learn from the experience?
                              • {name}
                              What else do you want us to know about you?
                              • {name}
                              REFERRAL SOURCE
                                How did you hear about Type 1 Way Ticket?
                                Let us know if there's a specific person we should thank :)
                                • {name}
                                ENROLLMENT ELIGIBILITY CRITERIA & PROGRAM RULES
                                  I, the traveler, confirm that I have read and agree to Type 1 Way Ticket's Enrollment Eligibility Criteria.
                                  I, the parent/guardian, confirm that I have read and agree to Type 1 Way Ticket's Enrollment Eligibility Criteria.
                                  I, the traveler, confirm that I have read and agree to Type 1 Way Ticket's Program Rules
                                  I, the parent/guardian, confirm that I have read and agree to Type 1 Way Ticket's Program Rules
                                  PROGRAM FEE PAYMENT PREFERENCE
                                  Upon submitting your application, you will be prompted to pay the $500 deposit. Please note: deposits are non-refundable unless you are not offered enrollment. Please select whether you would prefer to pay the program fee (less the deposit) in full or on an interest-free monthly installment plan. Your preference will not have bearing on your admission–it only has bearing on how we bill you.
                                    I would prefer to pay the program fee
                                    OPTIONAL FEEDBACK
                                    Type 1 Way Ticket respects all forms of diversity and individuality, and we strive to use inclusive language in our application process. Your feedback will help us actualize our commitment to inclusion.
                                      Did you feel that the language used in this application was inclusive and/or reflective of your identity?
                                      Did you feel that the language used in this application was affirming of how medical and mental health conditions–past and present–do not automatically disqualify you from T1WT participation?
                                      What feedback do you have regarding how we can do better to be inclusive in our application process?
                                      • {name}
                                      IF YOU ARE NOT AUTOMATICALLY REDIRECTED TO PAY YOUR PROGRAM DEPOSIT AFTER SUBMITTING THIS FORM, PLEASE REFER TO THE LINK YOU RECEIVED VIA EMAIL TO DO SO.

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