Work & Travel Application

2023-2024
Alliance Group Travel
Calle 2 de Mayo 516 of. 201 Miraflores PHOTO
Lima - Perú
Tel: 511 7073567
Email: info@alliperu.com
Website: www.alliperu.com

Name of University: _____________________________________________________________________________

PERSONAL DATA - Name as it appears in the passport DNI: __________________

______________________________________________________________________________________________
Family Name First Name Middle Name

Birth date: __________________________ Gender: Male__ Female__

Month Day Year

Marital Status: Married__ Single__ Children: Yes__ No __

Place of Birth: City: ____________________________ Country: ________________________________________

Country of Citizenship: ________________Country of Permanent Legal Residency: ___________________________

Permanent legal residency indicates you have permission to live in this country, normally without a visa. For most people this will be the same country
as your passport.

Please include a copy of the main page of your passport with this application.

PERMANENT ADDRESS
_____________________________________________________________________________________________________________________________ __
Address

__________________________________________________________________________________
City Postal Code Country

__________________________________________________
Telephone (with country code)

Participant email address: ______________________________________________________________

Most of the communication between Alliance, Sponsor and the participant will
be via email. It is very important you provide an email address that is valid and
one that you can use in your home country as well as when you are in the US.

WORK & TRAVEL SITE INFORMATION

Name of Work & Travel Site: _____________________________________ Length of Work & Travel (Months): ________

Dates you want to work: (month/day/year) Start: ________________ End: _______________

Make sure that the dates you want to work are within the dates of your University’s official summer break. You can only work in the US during your
University’s Official summer break dates. In order to successfully complete the work and travel program, you MUST work the exact dates you agree to
when you sign a job offer for employment. The above dates will be used by your employer to determine the dates of your employment.

EMERGENCY CONTACTS
_____________________________________________________________________________________________________________________________ ________
Name of emergency contact in your home country Relationship Telephone

______________________________________________________________________________________
Name of emergency contact in the US (if applicable) Relationship Telephone

1
Participant’s Name: ___________________________________ DNI: ___________________________________

PREVIOUS J1
Have you previously participated on a J-1 visa program in the United States? Yes __ No __
If you answered yes, please complete the following questions:

What category was the J-1 visa? Work & Travel ____ High School ____ Other: ____

How many times have you previously participated on the J1 Program? ________________________________________

Name of Organization that sponsored your visa? _________________________________________________________

EDUCATION

Are you currently enrolled as a full time University student? Yes ___ No ___

I certify that I am enrolled full time at ______________________________________________which

is an accredited academic classroom based University.

Field of Study: ___________________________________________________________________

Please include a current and complete Resume/CV with your application.

STUDENT STATUS - to be completed and signed by the student

Student Name______________________________________________________________________

Name and Address of University: _______________________________________________________

_______________________________________________________

The University’s official dates for summer vacation are from _______________ until ________________
Month Day Year Month Day Year

__________________________ needs to be back at the University on _______________ to continue his

Students Name Month Day Year

or her schooling. When is the participant’s expected graduation date: _______________

Month Day Year

What degree or certificate, if any, is the student expected to earn? ______________________________

_______________________________________ is a current full time student of above university and is registered as
a full time student for the next academic year.
Students Name

Student´s Signature: _______________________________________ Date:______________________

An official letter from the University that is on University

letterhead, signed by an official of the University and
sealed must be submitted as proof of student status, but
the letter must state that you are a current full time student
and must include the official University summer vacation
dates. The letter MUST be in English or be sent with an
translation.

2
WORK & TRAVEL PROGRAM AGREEMENT DNI: _____________________
Before you finalize your application for the Work & Travel Program, it is essential you read this statement thoroughly and
understand your areas of responsibility. If you have any questions please ask Alliance before you sign this agreement.

Voluntary ignorance will not release you of your responsibilities. I, _________________________, undersigned, understand
and agree to the following:

• I understand and agree that the purpose of this program is cultural exchange. I do not expect to earn more money than to cover the
cost of my basic needs while in the United States such as food, public transportation, housing, and necessities. I do not expect to be
able to save money to take home. I understand I will probably not earn sufficient funds to pay for my airplane tickets, insurance fees
and program fees as part of this cultural exchange.
• I understand that it is my responsibility to give my arrival information to Alliance or Sponsor at least 2 weeks prior to my arrival. If
transportation and/or housing are provided, that information will be vital in ensuring that everything is ready for my arrival.
• I have been advised and agree that I must arrive with enough money to cover food, housing cost, transportation, deposits, and that it
may be 2-3 weeks before I receive my first paycheck.
• I understand that I must validate my visa within 72 hours of arriving to my employer. This means that I must contact my Sponsor by
visiting their website, calling, emailing, or faxing them my living address. My living address includes street, apartment # (if applicable)
city, state, and postal code. This information must be given to ensure that I receive my social security card and keep my visa in good
standing. Failure to validate my visa as instructed will result in my visa sponsorship being withdrawn.
• I understand that if I do not already have a Social Security Card, I must apply for one after I have been in the US for at least 10 days
and at least 3 days after I have validated my visa. If I apply for my Social Security card before this time, I may not receive it --making it
very difficult for my employer to pay me, to get a 2nd job, and to receive my taxes back the year following my program.
• I understand that I must provide a valid email address to my Sponsor. I will be required to check this email address on a weekly basis
for required communication with my Sponsor. It is my responsibility to answer these emails and communicate with my Sponsor in a
timely manner. At a minimum I am required to communicate with my Sponsor on a monthly basis. Failure to stay in communication with
my Sponsor will result in my visa sponsorship being withdrawn.
• I understand that in these communications with my sponsor I may be provided with information on how to enhance my cultural exchange
program. I understand this is a cultural exchange program and will make every effort to use this information to take part in cultural
exchange while in the US. Only by taking part in these experiences can I truly experience the program as it is meant to be.
• I understand that I am able to get a 2nd job while on the program. However, the job for which I am sponsored must take first priority. I
may not miss work at my sponsored job to attend work at my 2nd job. In addition I must receive permission in advance from my sponsor
in order to work at this second job. To receive permission I will need to provide to my sponsor with a job offer form, host site agreement,
workers compensation form, verification of the employers Tax ID number and a copy of the employer’s business license. My sponsor
will review this paperwork and only upon their approval may I begin working the 2nd job.
• I understand that there are certain positions in which I may not work. A few examples of these include domestic help
position in private homes (e.g. childcare, elder care, gardener, chauffeur); as a pedi-cab or rolling chair driver or operator;
and as operator of a vehicle or vessel that carriers passengers for hire and/or for which a commercial drivers license is
required or in positions requiring work hours that fall predominantly between 10:00p.m. & 6:00a.m. When looking for a
2nd job, it is my responsibility to communicate to my sponsor about the position I am applying for. I understand and agree
that I will NOT begin working in any position or for any employer without permission from my sponsor. I understand that
if I find a position I want to work in, but my sponsor declares that position to be prohibited, I may NOT work in that
position. I understand that if I find a position that I want to work in, and this position is not on the prohibited jobs list, I
still may NOT working in this position until my Sponsor has fully vetted the employer and given me permission. Failure
to follow these rules will result in the loss of my visa sponsorship.”
• I agree to live by the rules and expectations of my employer such as observing the expectations about dress code, personal hygiene,
timeliness, attendance, professionalism, positive co-worker relationships, etc.
• I understand that my employer will be requiring me to do my job, which at times will require hard work. My job may include, among other
things, being on my feet for long hours, lifting heavy objects, being at the call of clients of my employer, and doing tasks that I do not
find enjoyable. It is my responsibility to complete my work to the best of my ability, in a timely manner with a positive and professional
attitude.
• I understand that if I do not live by the rules and expectations of my employer, and if I am not able to complete my job as described
above, I may be terminated from my job. If this happens I may be required to return home within 7 days of my termination.
• I understand that I am bound by local, state and federal statutes. I am to obey all applicable local, state and federal laws. My Sponsor
reserves the right to terminate a participant's program should their conduct or actions be deemed harmful to themselves, the Work &
Travel site or the public at large. Work positions cannot be guaranteed. The Work &Travel site reserves the right to assign jobs on
availability. Participants are not guaranteed the option of overtime. Please refer to the job offer for additional details on working hours.

3
 • I understand that I am required to comply with reasonable requests by the Work & Travel site to modify behavior and/or stop any
inappropriate behavior.
• I agree to refrain from using drugs of any kind, other than drugs prescribed to me for health purposes. The illicit and/or irresponsible use of
drugs and alcohol is cause for immediate dismissal from the program. If I have drugs that are prescribed to me for health purposes, I will
inform to my sponsor during the application process, prior to coming on the program. I will also make the necessary arrangements to
insure these medications are available to me throughout the entire duration of my program.
• I understand that I agree to do my best to complete the Work & Travel program. Should I be unable to complete the program, I will no longer
be authorized by my Sponsor to remain in the Work & Travel program for work or travel purposes. My Sponsor and/or the Work & Travel site
will assist me to coordinate my immediate return home. Should I not return home, My sponsor is required to report that that I am out of status
and that my sponsor believes I am not returning home. Such actions could result in my inability to obtain a visa for the United States in the
future.
• I understand that I may not quit or resign from my job prior to receiving permission from my sponsor. If I do quit/resign from my job, I will be
in violation of the rules and regulations of the Work & Travel Program and may have to return to my home country within 7 days.
• I understand that I may not transfer jobs without prior permission from my sponsor. I must receive confirmation from my sponsor before I
leave my current employer. If I leave my original employer without permission, I will be in violation of the rules and regulations of the Work &
Travel Program and may have to return to my home country within 7 days.
• I understand that to receive permission from my sponsor to transfer jobs I will need to provide to my sponsor with a job offer form, host site
agreement, workers compensation form, verification of the employers Tax ID number and a copy of the employers business license. My
sponsor will review this paperwork and only upon their approval may I transfer to the new job.
• I understand that I am expected to respect the property of others, the Work & Travel site and the housing facilities. Destruction and/or theft
of property will be grounds for eviction and/or disciplinary action.
• I understand that I must be continuously employed by the Work & Travel site during tenure in the employer provided housing. Failure to
remain continuously employed will result in immediate eviction. Likewise, moving out of the employer provided housing will lead to the
termination of my employment.
• The Work & Travel site and my sponsor reserve the right to dismiss a participant at any time should a condition arise which, in the judgment
of the Work & Travel site and my sponsor, is likely to be detrimental to the health or safety of the participant. Further, the Work & Travel site
and my sponsor reserve the right to dismiss if the participant should violate the standards of conduct at the organization, or for other
disciplinary or legal problems in the community at large. The participant will return to his/her home country at his/her own expense within 7
days.
• I understand that I agree to provide to my employer and my sponsor my last day of work and departure date, at the time of the application
process and adhere to this date. It is my responsibility to verify my university's start date prior to giving my last date of work to my employer
and to my sponsor. Applicant acceptance by the Work & Travel site is based in part on this information.
• I understand that my sponsor will expect me to work until the last day of work that I provide. I will not be allowed to leave my job early for
any reason other than a family or medical emergency (documentation is required).
• I understand that the travel portion (also known as the grace period) of my program is only allowed if I successfully complete the program.
If I fail to successfully complete the program, I will be required to return home within 7 days and will not be allowed to travel.
• I understand that the insurance coverage coordinated through my sponsor is not responsible for any medical expenses that are a direct
result of engaging in criminal activities, including driving while intoxicated, etc., or for any pre-existing conditions. The insurance does not
cover you if you are a driver of a motor vehicle, but you can purchase this additional coverage.
• I understand that according to the rules of the program, I must return to my home country to begin University on the date it begins even if
that date is before the end of the 30 day travel portion (grace period) or my program.
• I understand that I will ask for clarification of any part of this program, prior to my departure to the US and the start of the Work & Travel
program. This includes reading thoroughly and understanding all the program information by my sponsor and Alliance provided to the
participants prior to departure.
• I agree to complete any written and oral evaluations required by the employer, my sponsor or Alliance to comply with government and
program regulations.
• I understand and agree that I am over 18 years of age, which, in the US, makes me an adult. This means that I will be held accountable for
the forms that I sign. It is my responsibility to ensure that I understand everything I am signing.

In signing this agreement, I acknowledge that I have read, understood, and agree to all the terms and conditions
of my own free will stated above. Again please remember the following: Voluntary ignorance will not release you
of your responsibilities!

Participant’s Signature:_______________________________ Date: _______________________

Printed Name:_______________________________________ DNI: _______________________

4
MEDICAL STATEMENT
Applicant’s Name:_______________________________
Do you now have, or have you ever had, any of the following? Check all that apply. (If yes, give detailed information regarding
impairment in the “Explanation” space provided below.)
DISORDERS NO YES Have you ever been hospitalized? ____YES ____ NO
Are you currently taking medications or injections? ____YES ____ NO
Seizure Disorders ___ ___ Do you presently have any diagnosed condition requiring
ongoing treatment or check-ups? ____YES ____ NO
Sleepwalking ___ ___ Do you have any additional pre-existing medical conditions? ____YES ____ NO
Appendectomy ___ ___ Explain in
detail all “YES”
Cough (frequent) ___ ___ answers of the
medical questions
Diabetes Militus ___ ___

Headache (persistent) ___ ___ Are you able to work in a physically demanding job? ____YES ____ NO
Please rate your physical condition: _____ Good _____ Fair ______ Poor
Menstrual Disorders ___ ___
If you have any of the above disorders or are taking any medications/injections or have
Learning or Speech Defects ___ ___ pre existing medical conditions. You might not be physically able to work in every
position. It is very important that you read and understand the physical job description
Vertigo, Dizziness ___ ___ of a position before your sign the job offer. If you agree to do a job that you know you
can not physically do, you might have to return home before the end of your program. It
Allergies ___ ___ is also very important that you read and understand what is medically covered while
you are in the US. Preexisting conditions are not covered under the current insurance
Asthma ___ ___ plan provided by the sponsor.

Anorexia/Bulimia ___ ___

GENERAL MEDICAL RELEASE AGREEMENT

I, the undersigned, authorize any hospital or other medical-care institution, physician or other medical professional, pharmacy, Insurance support
organization, governmental agency, group policyholder, insurance company, association, employer or benefit plan administrator to furnish to my
sponsor, the Insurance Company arranged for me by my sponsor or its representatives, any and all confidential health information with respect to any
injury or sickness suffered by, the medical history of, or any consultation, prescription or treatment provided to, the undersigned whose death, injury,
sickness or loss is the basis of a claim and copies of all of that person's hospital or medical records, including information relating to mental illness and
use of drugs and alcohol, to determine eligibility for benefit payments under the insurance policy which is arranged for me by my sponsor. I authorize
the policyholder, employer or benefit plan administrator to provide to my sponsor, the Insurance Company which is arranged for me by my sponsor or
its representatives with financial and employment-related information. I understand that this authorization is valid for the term of coverage of the policy
or the duration of any claim for benefits under the policy, but in no event longer than 24 months.

I agree that a photographic copy of this Authorization shall be as valid as the original. I understand that I or my authorized representative may request
a copy of this authorization.

The protected health information provided under this authorization may include diagnosis and treatment information, including information pertaining
to chronic diseases, behavioral health conditions, alcohol or substance abuse, communicable diseases, including HIV/AIDS, and/or genetic marker
information. Information disclosed under this authorization may be re-disclosed by the recipient and no longer protected by federal privacy regulations.

I understand that I or my authorized representative may revoke this authorization at any time, by providing to my sponsor, the Insurance Company
which is arranged for me by my sponsor or its representatives with written notification as to my intent to revoke. I do understand that, if I do not sign
this authorization, my sponsor, the Insurance Company which is arranged for me by my sponsor or its representatives may not be able to obtain health
information necessary to consider my claim for benefits.

I grant my sponsor permission to act on my behalf in anything pertaining to possible representation before the local authorities. This authorization
shall be valid the entire duration of the Work and Travel program in which I am participating.

Participant Signature: _________________________________________________________________ DNI: _________________________________

Participant Name: _____________________________________________________________________Date: _________________________________

__

5
LIABILITY RELEASE

I understand that, as a participant, I will be subject to the authority of my sponsor and must follow the rules provided by the program and host site. I
also understand that my sponsor reserves the right to terminate sponsorship in the program of any participant whose conduct during the program
period may be considered detrimental or incompatible with the interest and security of the program. If this decision is ever taken, the participant will
have no right to any refunds.

I accept the right of my sponsor to directly or indirectly cancel, change, or substitute in emergencies or whenever normal circumstances change, those
elements of the program whose alteration is deemed necessary by sponsor. I understand that should there be a geographic move of the participant
for any reason whatsoever, the cost of the transportation shall be borne by the participant.

I grant to my sponsor permission to use in the future any photographic or any other type of material in which I, the participant may appear for promotion
or publicity of the organization's programs.

I authorize to my sponsor to return me to my home country of origin at my cost, if necessary, to submit to medical treatment, if this is deemed necessary
by the above-mentioned people, after consultation with medical authorities. I confirm that at the time of signing this document that I enjoy satisfactory
physical and mental health, that my health record enclosed herewith is true and complete, and that I may engage in any physical or sport activity.

I grant to my sponsor permission to act on my behalf in anything pertaining to possible representation before the local authorities. This authorization
shall be valid the entire duration of the Work and Travel Program in which I am participating.
Participant Signature: ____________________________________________________________

Participant Name: _______________________________________________________________ Date: ___________________________________________________

INTERVIEW cONFIRMATION COMPLETED BY ALLIANCE

Participant’s name: __________________________________________

This area is to be completed by Alliance:

The Work & Travel Program Goal is to achieve the educational objectives of international exchange by involving foreign
university students during their summer vacations directly in the daily life of the US through travel and employment
opportunities.

I have discussed with the above named student the Work & Travel Program, its rules and regulations in detail, as well as
the different possible work & travel sites available with this program.

I certify that I have reviewed what the Work & Travel Program Goal is with the participant, and that I have reviewed the
participant’s qualifications and experience and can substantiate that the above named student has appropriate education,
skills and experience to benefit from the Work & Travel Program.

• Date of Interview: _____________________________________________________________________

• Place of Interview: ____________________________________________________________________

• Method of Interview: __________________________________________________________________

• Interviewer Name: ____________________________________________________________________

• Signature of Interviewer: ______________________________________________________________