Impact Africa Volunteering Application Form

Please print
Personal Information
First Name...................................................................
Middle Name.
Last Name ...................................................................
Address .......................................................................
City /State/ Zip. ............................................................
Telephone ...................................................................
Date of Birth ................................................................
Marital Status: ..

Please circle correct response:

Gender:

Male

Female

Physical Limitations:

YES / NO

If Yes (Please Explain):

..

Education Background
A. University
Name/Place/Country

B. Schools or other
form of training

Years
Atended

Academic distinction
obtained

Main Course of Study

Years
Attended

Academic distinction
obtained

Main Course of Study

Employment Record (Volunteer or otherwise)

Duration of Contract

Exact Title of post

Type of Work Done

Skills (List your skills and indicate proficiency level)

1. .................................................................................... ........................................................................................
2..................................................................................... ........................................................................................
3..................................................................................... ........................................................................................

Languages

Fluent

Read

Write

1..................................................................................... ........................................................................................
2..................................................................................... ........................................................................................

Volunteer availability: (Circle all applicable)

Number of Days per week: 1 2 3 4 5
Monday

Tuesday

Wednesday

Thursday

Friday

No Preference

Emergency Contact:
First Name..........................................................
Last Name ..........................................................
Address ..............................................................
City/State/Zip......................................................
Telephone ..........................................................

Housing, Food, Security is provided for at the hospital premises.

Volunteers hereby agree to serve any client who is assigned regardless of race, sex, creed or national
origin.

....................................................................................... ........................................................................................
(Signature/Volunteer)
(Date)