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Registration form must be in English. Please type or print legibly.

VOLUNTEER REGISTRATION FORM
To
year

Programme Period Runs From
month

/

day

/

/ month

/ day

*Attach your Passport-Size Photograph Here
year

I. Personal Information
Last Name (Surname)
(exactly as shown on your passport)

First Name

(exactly as shown on your passport)

Middle Name(s)

(exactly as shown on your passport)

Nationality
Male Female

Home Mailing Address

E-mail Address(es)

Work Telephone Number

(Include country / local area codes)

Home Telephone Number

(Include country / local area codes)

Mobile Telephone Number

(Include country / local area codes)

Date of Birth (month/date/year) / Passport Number /

City and Country of Birth Passport Issue Date
/ /

Current employer Name of person to contact in case of an emergency

Passport Expiration Date
/ /

Country Issuing Passport

month

day

year

month

day

year

Emergency contact person’s telephone number

(Include country / local area codes)

CANCER AWARENESS AND SUPPORT CENTRE

II. Academic Education
Please list each College or University you have been enrolled in, beginning with the most recent. If you need additional space, please attach a separate sheet and include your full name on it.

Name of Institution and Country

Major Field of Study

Dates Attended / /
month / year month / year

Degree Earned

Date Completed
month / year month / year month / year

month / year

----

month / year

/ /

/

month / year month / year

/ /

/

/

III. Technical / Professional Training or Courses
Please list each relevant technical / professional training or courses you have completed, beginning with the most recent.

Name of Training or Course /

Dates ----/

Language of Instruction

Country of Instruction

month / year month / year month / year

month / year

/

month / year month / year

/

/

/

month / year

/

month / year

/

IV. Current Employment
Organization or Company Name / Department Web Site Address
HTTP://

Mailing Address and Telephone Number

Dates of Employment
Month

Your Position Title
month

/

year

--

/

year

Supervisor’s Name / Position Title / Department

Supervisor’s E-mail Address

Supervisor’s Telephone Number
(Include country / local area codes)

Duties: Please concisely describe your current job-related responsibilities and accomplishments

CANCER AWARENESS AND SUPPORT CENTRE

V. Applicant Certification
I, certify that all information provided on this

registration form is true to the best of my knowledge.

Print your full Name

Applicant’s Signature

Date

VI. Approval of Employer
I certify that
Print Applicant’s Full Name

is a staff member at

and is under my supervision. I agree to his/her registration with CASC for volunteer programme.

Name of Institution

Signature of authorized institutional representative Print name and position title

Date

CONDITIONS OF THE VOLUNTEER PROGRAMME

DECLARATION If I am accepted to CASC volunteer programme, I agree to adhere to the arranged program, to devote my time and attention to my work to conform to the CASC internal regulations and procedures for the duration of my stay. I agree to conform to all laws of Kenya. Furthermore, I certify that I understand and agree with the following policies of the volunteer Program: I. Conditions for Termination of Volunteer Programme: CASC reserves the right to terminate the volunteer program of those participants who: A. Fail to show sufficient interest in their work during the volunteer programme; B. Have severe mental or physical health problems. C. Conduct themselves in a manner prejudicial to the program or to the laws Kenya. D. Have falsified information on the registartion

CANCER AWARENESS AND SUPPORT CENTRE

II. Financial Support: The applicant is aware that CASC is not providing any support in travel, emergency medical insurance, lodging and food. All the costs in respect to volunteer's stay in Kenya will be borne by the participant. CASC will provide logistics to the participant. III. Health and Insurance: Whereas health insurance is not a requirement for this volunteer programme, it is advisable that the participant procures a travel and a health insurance for the period of stay in Kenya. IV. Debts and Obligations: The participant will be responsible for all debts and financial obligations incurred while in Kenya Signature below indicates understanding and agreement of the above terms and conditions.

Applicant's Signature

Date

CANCER AWARENESS AND SUPPORT CENTRE

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