Application for Volunteer Service

at Blessed Gérard's Care Centre

in Mandeni, kwaZulu/Natal, Republic of South Africa

You may download this application form in Acrobat Reader format.
If you need the software to read and print the document, you may download it here free of charge:

Please make sure, that your application reaches us as early as possible to enable us to process it.
Please be aware that the acceptance of your application is made at our discretion and depends on the availability of volunteer positions at the proposed time.

Please print this page, complete it in block letters and in full and send the original per (snail) mail to:

Brotherhood of Blessed Gérard
P O Box 440
Mandeni 4490
Republic of South Africa

Surname
First Names
Residential address Street
Postal Code
City
Country
Postal address
(if different)		 Post Box
Postal Code
City
Country
Telephone Area Code
Number
Fax Area Code
Number
e-mail address
Date of birth
Sex
Marital status
Which church do you belong to?
Citizenship
Do you have any dietary restrictions?
If yes, please explain in detail
Highest Standard of Education
Other qualifications
Home language
What other languages do you speak
Do you have an international driver’s licence?
If no, are you prepared to get one?
Would you be covered by medical and accident insurance?
DETAILS OF AT LEAST TWO NEXT OF KIN
1. 2.
Family Name Family Name
Title & First Name Title & First Name
Relationship Relationship
Address

 

 Address

 
Home Telephone Number
(please include area code)		 Home Telephone Number
(please include area code)
Occupation Occupation
Business Telephone Number Business Telephone Number
Emergency Telephone Number
(if different from above)		 Emergency Telephone Number
(if different from above)
What do you expect to gain from this experience?
 
 
 
 

Please give details of any other volunteer work in which you have been involved.

Name of organisation type of work done period spent working for them Remarks
       
       

 
       

 
       

 
 

Arrival

Departure
State date you would be available to come to Mandeni    
Give two alternate dates
in order of preference 		1
2
Is there any other information which you think might be relevant
 
 
 

I have read the "Information for Prospective Volunteer Helpers" and declare that I understand it fully and agree to abide by all the regulations as mentioned therein.

Date                           Place                          Signature

_____________________________________________________

Please attach a recent photograph.

Medical Questionnaire
for prospective volunteers at
Blessed Gérard's Care Centre

Applicant’s Surname

  

First Names

  

Date of Birth

  
  YES NO
Is the applicant fit to work in a country with a sub-tropical climate (i.e. at high temperatures and high humidity)?    
Is the applicant physically capable of carrying out general nursing duties (incl. lifting patients, carrying them on a stretcher, walking in a rough terrain etc.)
If "No" please specify disability _____________________________________________________		    
Does the applicant suffer from epilepsy, multiple sclerosis or other neurological disease?    
Does the applicant suffer or carry germs from any contagious disease (e.g. Tuberculosis, Typhus, Hepatitis, HIV/AIDS)    
Is the applicant addicted to drugs or alcohol or any other substance?    
Is the applicant mentally stable and psychologically balanced?    
Does the applicant need regular medical attention by a doctor?    
Does the applicant have to take any medication on a regular basis?
(If "Yes", please provide him/her with a sufficient supply/prescription of all necessary medication!)		    
Phone number of applicant’s doctor, which the Brotherhood of Blessed Gérard may contact (in case of emergency only)
Remarks (if any)

 

The applicant has assured me, that he/she gives permission to disclose the given information.

Signed at _____________________ on this__________________

 

Signature of Medical Doctor                                 Stamp

 Church Questionnaire
for prospective volunteers at
Blessed Gérard's Care Centre

Applicant’s Surname

  

First Names

  

Date of Birth

  

For how long (approximately) have you known the applicant?

  

Which church/denomination does the applicant belong to?

  

Is the applicant baptised?

 Yes No

Confirmed?

 Yes No

Married?

 Yes No

Ordained?

 Yes No

Does the applicant actively take part in the life of the church?

 Yes No

Which church activities is the applicant especially involved in?

  

Do you think the applicant will feel comfortable working in the church environment of a Catholic Relief Organisation?

 Yes No
Are there any further reasons, why you would recommend the applicant?  

 

Signed at ___________________ on the __________________________

Place                                   Date

 

 

_____________________________________________ __________________________

Signature of Parish Priest                                           Stamp