Please complete the details below as they appear on your passport.
First and Middle Names:
Your Current Occupation
Dates available to work with us:
Post Code/Zip Code:
Place and Date of Issue:
Emergency Contact (Name):
I understand that the Ponheary Ly Foundation is against sexual relationships with children and I confirm that I have never engaged in sexual relationships with children. I authorize the Ponheary Ly Foundation to make any investigations it deems appropriate to verify this. Further, I understand that if I appear to be engaging in such conduct I will be dismissed and reported to the authorities in Cambodia and in my home country.
I agree to the statement "Sexual Relationships with Children" above: Yes No
1. I, in full recognition and appreciation of the dangers and hazards involved in such activity, do hereby agree to assume all risks and responsibilities surrounding my participation of this trip to Ponheary Ly Foundation Schools, on the date described above. I do hereby release and hold harmless Ponheary Ly Foundation (PLF) , its Trustees, Officers, Directors, Faculty and Employees, and participants from and against any and all liabilities to the undersigned, his/her dependents, assigns,participants from and against any and all liabilities to the undersigned, his/her dependents, assigns, personal representatives, heirs and next of kin for any and all damages, expenses (including attorney fees) claims, judgments, actions or causes of action as a result of any loss or injury to the person or property, including death which the participants listed below may sustain or suffer during or arising out of activities of the above described event and during transportation to and from such event whether caused by negligence of PLF, of persons active on its behalf or otherwise.
2. I understand that Ponheary Ly Foundation does not, in any manner, serve as principal, agent, or partner of any travel agent or commercial carrier which may provide services or to the participants. I have read and understand this release and voluntarily sign the document and participate in this trip.
3. In the event of injury to the undersigned, or any family participants listed above, I hereby authorize Ponheary Ly Foundation or representatives thereof to admit me or any member of my family to a facility for emergency medical treatment as may be deemed necessary to our health or welfare.
4. I hereby consent to whatever medical treatment is deemed necessary. I, on my behalf, and on behalf of my heirs, successors, assigns, and personal representatives, hereby release Ponheary Ly Foundation , its trustees, officers, faculty and employees from any and all claims arising from my admission to such facility or from such treatment administered by such facility.
5. I declare that all parties are participating in this visit solely at our own risk and indemnify Ponheary Ly Foundation (PLF) its Trustees, Officers, Directors, Faculty and Employees, and participants in respect of any claim arising out of our visit.
6. I understand that we will have to cooperate fully with the hosts of the school and the PLF and their employees and will diligently comply with all associate rules regarding safety.
I agree to the statement "Contract with Volunteers and Visitors" above: Yes No
I understand that I will be required to carry traveler's insurance that includes medical evacuation while I am volunteering. A copy of this document must be forwarded to "firstname.lastname@example.org " 1 week prior to arrival. I understand that failure to produce such paperwork will cause me to be removed from the volunteer schedule. Yes No
Which program(s) are you most interested in? Why?
Do you have any special skills, hobbies, or passions that could be relevant to our classroom needs?
Have you traveled/worked/volunteered in "developing" countries before? If so, where? What did you do?
Why do you want to be a PLF Volunteer?
Can you think of any detrimental aspects of voluntourism?
How did you find out about Ponheary Ly Foundation?
If you are volunteering with other people, please list their names here.
Are you a native English speaker? Yes No
Do you have an ESL Certificate? Yes No(not required)
If there are two of you teaching in the same class, traveling to the school together and sharing a room, this cost would be for two people.
Expenses will be collected from you in Siem Reap in cash on the first day of your placement and are usually non-refundable.
Please email us if you are staying longer than 3 weeks. Costs for lodging will be reduced in that case. If you have made some other agreement with PLF about housing/transport costs (such as in the case of a long term stay) note them here (optional):
I agree to the statement "Cost of being a Volunteer" above: Yes No
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0307 Wat Bo Rd
Siem Reap, Cambodia
PO Box 17034
Austin, TX 78760