TEAM PREFERENCE

In 2012 teams will begin May 24 and run through the end of June. You may choose a 1, 2, or 3 week team. Please select your preference. You will be notified of your team date at the end of January.

 1 Week Team 2 Week Team 3 Week Team

Please list any dates you will NOT be available.

PERSONAL INFORMATION

First Name

Last Name

Preferred Name 

Date of Birth (dd-mm-yyyy) 

Gender  Male  Female

Phone Number 

Email Address

Current Address 

City 

State 

Zip Code 

Permanent Address 

City 

State

Zip Code 

How did you learn about Care for Life?

Please tell us why you would like to volunteer in Mozambique and how you can contribute.

BACKGROUND INFORMATION

List your education and previous volunteer experience.

PERSONAL REFERENCES

References should not include relatives. Church leaders, teachers, and employers are preferred.

REFERENCE #1

Name

Phone 

Email 

Address 

REFERENCE #2

Name 

Phone 

Email 

Address 

REFERENCE #3

Name 

Phone 

Email 

Address 

MEDICAL HISTORY

Blood Type

Please list/describe any illnesses, injuries, or operations you have had.

Have you ever suffered from any psychiatric or psychological problem,
including anxiety or depression. If so, describe list below.

Please list any allergies.

Have you ever been convicted of a crime? If so, please explain.

EMERGENCY CONTACT INFORMATION

Name

Phone

Cell Phone 

Email 

Address 

Relationship