Summer Work and Travel usa application istplus com/watusa Congratulations on applying for Summer Work and Travel! Next Steps

Name of CIEE Representative:

Country:

Interviewed by (Name):

Representative Code:

Date (day/month/year):

WORK & TRAVEL USA

APPLICATION

A Cultural Exchange Program 

Summer 2018

4 of 9

ciee.org/in-the-usa/work/work-travel-usa

1-888-COUNCIL (268-6245)

  [e-mail] 

Updated:  8/8/17

MEDICAL HISTORY

Have you ever been hospitalized? 

  

Yes 

    

No 

If yes, please explain: 

Have you ever been advised to have surgery which has not been done? 

  

Yes 

    

No

If yes, please explain: 

Have you ever consulted a neurologist, psychiatrist, psychologist, or any other specialist in nervous or emotional disorders? 

  

Yes 

    

No

If yes, please explain: 

When, and for what reason, did you last consult a physician? 

What diseases, ailments, or injuries have you had in the last year? 

Please mention any allergies, the severity of the allergy, and indicate if and how they are currently being treated. 

Do you have any physical limitations? 

  

Yes 

    

No

If yes, please explain: 

Please indicate any medication you are currently taking and its purpose. 

(Note: Bring this medication with you in a clearly labeled container that indicates its generic name.) 

If you are allergic to any medication, please list them here. 

Please indicate any other pertinent medical information that may have been omitted. 

(such as abnormal blood pressure, weight problems, etc.)

IST Plus

ALL APPLICANTS MUST COMPLETE THIS SECTION

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United Kingdom

UK/IST

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Name of CIEE Representative:

Country:

Interviewed by (Name):

Representative Code:

Date (day/month/year):

WORK & TRAVEL USA

APPLICATION

A Cultural Exchange Program 

Summer 2018

5 of 9

ciee.org/in-the-usa/work/work-travel-usa

1-888-COUNCIL (268-6245)

  [e-mail] 

Updated:  8/8/17

PRIVACY, HIPAA, AND CONFIDENTIALITY RELEASE FORM

By completing this form, you give consent to CIEE, your parents or guardian, and your physicians and/or other medical providers to discuss 

your medical and/or insurance issues with CIEE. You also consent to CIEE utilizing any such material as necessary in treating any medical 

condition that may arise. You also consent that CIEE may notify your emergency contact listed in this application of any situation that we deem 

to be an emergency. In addition, you consent that CIEE may notify the official CIEE designated agency from whom you purchased this program 

of any situation that we deem to be an emergency.

This authorization is valid for two years from the date signed.

Under no circumstances can CIEE release medical information from your physician or provider of service to you or anyone. Your medical 

information has been disclosed to us from your physician or provider of service, and we are prohibited by federal law from further disclosure. 

Please contact your physician or provider of service for your medical information.

I give CIEE permission to release any or all of the following information as appropriate in the event of a medical condition. 

Please initial and check each box.

Initial:  

  

All financial and claim information related to medical bills or Claimant’s Statement and Authorization.

Initial:  

  

Provider name, date of service, total charge, total paid, and date of payment.

Initial:  

  

Insurance ID number and/or social security number.

Print Patient Name:

Signature of the Patient, Adult Parent, or Guardian: 

Date 

(DD/MM/YYYY)

:

IST Plus

ALL APPLICANTS MUST COMPLETE THIS SECTION

** Don't forget to add your initials where requested!

IST Plus

United Kingdom

UK/IST

---

Name of CIEE Representative:

Country:

Interviewed by (Name):

Representative Code:

Date (day/month/year):

WORK & TRAVEL USA

APPLICATION

A Cultural Exchange Program 

Summer 2018

6 of 9

ciee.org/in-the-usa/work/work-travel-usa

1-888-COUNCIL (268-6245)

  [e-mail] 

Updated:  8/8/17

Applicant Responsibilities

1. The applicant agrees that all the information provided in 

the application is true to the best of his/her knowledge, and 

acknowledges that any false or misleading information may 

lead to immediate dismissal from the program.

2. The applicant acknowledges the aims and objectives of the 

CIEE Work & Travel USA program as a U.S. Department of 

State authorized Exchange Visitor Program, with the pur-

pose of providing qualified students with cultural exchange 

opportunities in the United States.

3.  The applicant is responsible for considering his/her personal 

health and safety needs when applying for or accepting 

a place on the program. If the applicant suffers from any 

health or other condition that would create a risk for him/

her while abroad, he/she should not apply.

4.  The applicant agrees to pay all fees in accordance with the 

requirements of the CIEE Representative through whom he/

she is submitting an application.

5.  The applicant is responsible for submitting all requested 

documentation to the CIEE Representative in a timely fash-

ion for visa processing. CIEE cannot be held responsible for 

any additional costs incurred (including the cost of rebook-

ing or canceling a flight) by the applicant due to delays in 

submitting documentation, verifying employment, or delays 

caused by the U.S. Embassy in processing visa applications, 

scheduling a visa interview, issuing a visa, or visa denial.

6.  Each applicant must pay the local visa fee to the U.S. 

Embassy. Applicants are responsible for any additional fees 

that might apply at the U.S. Embassy or Consulate in the 

country where they are applying for the visa, as well as the 

government SEVIS fee collected as part of the application.

7. All applicants must attend an interview and complete lan-

guage screening in order to participate on the program.

Participant Responsibilities

8. The participant understands that he/she is expected actively 

to participate in American cultural activities during the 

program. The participant agrees to make a good faith effort 

to seek out and participate in American cultural activities, 

and to interact with American citizens. CIEE will provide 

access to online learning and information about life in the 

U.S. Depending on timing and location, CIEE will provide 

opportunities to attend Connect USA events. Depending on 

timing, participants may be able to apply for the CIEE Civic 

Leadership Summit. The participant understands that com-

plete information about cultural exchange opportunities will 

be made available at a later date.

9. The participant confirms that he/she has reviewed the 

complete program pricing information provided and fully 

understood the costs of the program before paying a non-

refundable deposit. 

10.  The participant understands that he/she is expected to and 

must return home at the end of the program. Further, the 

participant recognizes the importance of sharing their cul-

tural experience with their home country

11.  Any Work & Travel USA participant who is withdrawn or ter-

minated from the program will be required to return home 

at his or her own expense. A terminated participant also 

loses his/her legal right to remain in the U.S. Termination 

may negatively impact the participant’s ability to obtain 

future U.S. visas.

12.  The participant is responsible for reading and carefully 

considering all materials made available that relate to safety, 

health, legal, environmental, political, cultural and religious 

customs, and conditions in the U.S. Each participant must 

take full responsibility in the event that laws, regulations, or 

customs are broken, regardless of foreknowledge. 

13.  Each participant is required to complete a CIEE Orientation.

14.  It is the responsibility of the participant to exercise due care 

once in possession of the legal documentation (DS-2019) 

and visa. The cost of replacing these items must be borne by 

the participant.

15.  The participant must supply CIEE with the name and contact 

details for an emergency contact, to be contacted in the 

case of emergency. These details must be included on the 

application form.

16.  The participant is responsible for all of his or her acts along 

with any loss or damage resulting therefrom while on the 

program. The participant agrees to indemnify and hold 

harmless CIEE and any other party who or which has 

suffered a loss to any person or property caused by reason 

of the participant’s conduct.

17. All travel before, during, and after the program is at the 

participant’s own risk. Any participant who chooses to 

operate motorized vehicles is responsible for obtaining the 

necessary license, permission, and insurance and does so at 

his/her own risk.

18.  The participant agrees to comply rigorously with the 

monitoring schedule set up by CIEE. The participant agrees 

to respond in a timely manner to any CIEE communica-

tion requiring a response. Failure to comply with the CIEE 

monitoring schedule will result in the participant’s J-1 Visa 

program being terminated, which may negatively impact the 

participant’s ability to obtain future U.S. visas. 

19.  The participant must have at least US$800 with him or her 

upon arrival in the U.S. in order to support himself or herself

in the U.S. until he or she receives his/her first paycheck. 

The participant understands that wages might not cover 

the entirety of program and living expenses and that he/she 

should have access to additional personal funds.

20.  If, during the course of the program, the participant is 

evicted from housing, or is warned in writing that he or she 

is at risk of eviction, as a result of the participant’s behavior, 

partying, excessive noise, overcrowding, or other housing 

violations, this will be considered a violation of CIEE pro-

gram rules. CIEE reserves the right to revoke his/her legal 

sponsorship, which will result in the withdrawal or termina-

tion of his/her program.

21.  If, during the course of the program, the participant encoun-

ters any difficulties with safety, health, job, or housing, 

including charges or fees for housing, sanitary conditions, 

overcrowding, etc., or any other problem, the participant 

must notify CIEE as soon as possible by phoning CIEE at 1-888-

268-6245 (available 24 hours a day, 7 days a week).

22.  Participants on Work & Travel USA are required to comply 

with all U.S. Government visa and immigration 

requirements, including the SEVIS tracking as follows: 

a) notification of arrival in the U.S. to CIEE within 10 days 

of DS-2019 start date; b) providing a valid address, email 

address, and phone number upon arrival at U.S. employer; 

c) notification to CIEE of any change in U.S. home address, 

phone number, and/or email address within 10 days of 

change. Failure to comply with these requirements will result 

in the participant’s J-1 Visa program being terminated.

23.  Participants on Work & Travel USA are required to comply 

with all CIEE program rules, as listed in these program terms 

and conditions. If a participant violates any CIEE program 

rules, CIEE reserves the right to revoke his/her legal spon-

sorship, which will result in the withdrawal or termination of 

his/her program. 

24.  Participants on Work & Travel USA are required to comply 

with all U.S. laws while inside the United States. If a partici-

pant violates any U.S. law, CIEE reserves the right to revoke 

his/her legal sponsorship, which will result in the withdrawal 

or termination of his/her program. A terminated participant 

also loses his/her legal right to remain in the U.S. 

Employment or Job-Related Conditions

25.  Employment is typically in the hospitality or tourism indus-

tries. Participants typically work an average of 32-40 hours 

per week and are paid at least the federal minimum wage. 

Housing, food, and certain transportation costs are typically 

not included as part of compensation for work but may 

be deducted from your salary. Wages might not cover the 

entirety of program and living expenses.

26.  All employment, including second jobs, must be 

vetted and approved by CIEE prior to work commencing. 

CIEE reserves the right to deny any job according to the 

current and/or anticipated rules, regulations, and intent of 

the J-1 Exchange Visitor program. All jobs must be seasonal 

in nature and not displace year-round American workers. 

Employment that does not allow for meaningful cultural 

exchange with Americans is not permitted. Relevant factors 

include the job duties, workplace, geographical location, 

work schedule, and hours per week. Prohibited jobs include, 

but are not limited to, au pair, childcare provider, teacher, 

teaching assistant, camp counselor, pedicab operator, ship 

or aircraft crew member, jobs involving sustained physical 

contact with other people, medical staff having patient con-

tact, jobs involving driving a vehicle, jobs in gaming/gambling, 

jobs in manufacturing, jobs involving controlled hazardous 

substances, and jobs identified as hazardous to youth by the 

U.S. Department of Labor. Jobs in private households are 

not permitted. Jobs in the adult entertainment industry are 

not permitted, including but not limited to escort services, 

adult book/video stores, massage parlors, and strip clubs. 

Jobs with traveling concessions are not permitted. Jobs 

requiring shifts that are more than four hours between 

10:00pm and 6:00am are not permitted. From time to 

time the list of prohibited jobs is updated. More information 

is available on the CIEE Work & Travel USA website, 

ciee.org/in-the-usa/work

.

27.  Under no circumstances are job positions guaranteed. Even 

in the case when an employer represents that a job is being 

held, this does not constitute a binding contract that the job 

will be available when the participant arrives. The employer’s 

commitment is one of good faith only.

28.  If the participant does not have sufficient English skills and/

or does not arrive on time and/or has misrepresented any 

statement in the application, the job offer may be revoked.

29.  If the participant does not meet his or her contractual 

obligations to the employer or with CIEE, CIEE may at 

its sole discretion withdraw or terminate sponsorship of 

the participant.

30.  Participants must work for the employer listed on their Job 

Offer Form (JOF). If, for any reason, a change of employer 

becomes necessary, participants must contact CIEE and 

obtain written approval BEFORE changing jobs. If a partici-

pant leaves his/her employment without the prior written 

approval of CIEE, or engages in employment without the 

prior approval of CIEE, CIEE reserves the right to revoke his/

her legal sponsorship, which will result in the termination of 

his/her program and his/her legal right to remain in the U.S.

31.  Participants on Work & Travel USA are required to maintain 

communication with their employer prior to arrival, notify 

them in advance of their arrival and departure dates, and 

advise them of any changes to their travel itinerary due to 

visa delays or any unforeseen circumstances.

32.  Due to weather conditions, or other factors beyond CIEE’s 

control, some jobs have uncertain start dates and hours of 

work, and employment may become unavailable. CIEE and 

your representative are not responsible for the participant’s 

expenses due to these factors, financial difficulties of the 

employer, or any other reason not under the direct control 

of CIEE and your representative.

33.  Participants are solely responsible for their own conduct 

and well-being both on and off the job. CIEE cannot and 

does not monitor the participant’s personal conduct, 

subject, however, to the requirements of these Terms and 

Conditions. All participants must follow all United States, 

state, and local laws and regulations, and are subject to 

financial penalties, deportation, and/or incarceration for 

breaking laws.

34. If a CIEE-sourced job position is no longer available, through 

no fault of the participant’s own, after a signed JOF has been 

issued to the participant, or if for any reason CIEE deems it 

necessary to relocate a participant from a CIEE-sourced job 

either before the job commences or at any time during the 

job period, CIEE will assist the participant in finding another 

This form includes Terms and Conditions and releases CIEE (Council on International Educational Exchange) from liability. It must be signed by all participants.  

I agree that the following terms and conditions are binding on me and my adherence to them is imperative.

CONTRACTUAL TERMS AND CONDITIONS/PARTICIPANT DECLARATION

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**Please make sure you sign and date the bottom of the following 

page

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United Kingdom

UK/IST

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