Volunter Information Form

 

Personal Information

Full Name
Address
Phone Number
E-mail
Date of Birth
dd/mm/yy

IN CASE OF EMERGENCY CONTACT

Full Name :
Address :
Phone Number :
E-mail :
Relationship :

MEDICAL INFORMATION
Is their some pre-existing medical problem of which we should be aware?

Allergy :
Drug reaction /sensitivity :
Medecine you need to take:
Dietary requeriments:
Dietary preferences:
Other:

WHAT TIME PERIOD ARE YOU CONSIDERING?

Start Date :
dd/mm/yy
End Date :
dd/mm/yy
FOR OUR INFORMATION
HOW DID YOU HEAR ABOUT US?
WHICH PART OF OUR WORK PARTICULARLY INTERESTS YOU AND WHAT IS YOUR MOTIVATION FOR WANTING TO WORK WITH CHILDREN'S HOMES IN BOLIVIA?

 

AGREEMENTS:


In case of medical emergency, I consent to needed treatment as deemed necessary by an attending doctor or physician.
As a volunteer I absolve Bolivian Children's Mission its staff and administration from any and all liability arising from injury, damage or loss; personal or to property

I understand that I am travelling to/from Cochabamba, Bolivia and staying here at my own risk.
I understand that any violation of the policies of Bolivian Children's Mission with respect to demeanour, propriety and especially in respect to influences on minors will result in immediate dismissal from Bolivian Children's Mission premises and a suggestion that you return home.

Signature of Applicant Date (dd/mm/yyyy)


Signature of Parent/Guardian (if applicant is under 18 years of age) Date (dd/mm/yyyy)

 

 

 

 

 

B.C.M.

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