Blessed Gérard's Care Centre - Application for Volunteer Service

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)

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

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

	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.

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

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?

		Arrival	Departure
State date you would be available to come to Mandeni
Give two alternate dates in order of preference	1
Give two alternate dates in order of preference	2

Application for Volunteer Service