Volunteer Application

Title

Name:*

First Last

Address:*

Departure City (1st and 2nd choices):*

Home Phone:*

Cell Phone:*

Email Address:*

Emergency Contact (name, phone number, relationship):*

Please enter the NAME, PHONE NUMBER and RELATIONSHIP of someone NOT TRAVELING WITH YOU that we may contact in case of an emergency. A valid phone number is required.

Passport Number:

Name as listed on Passport:*

Please enter your name as it is LISTED ON YOUR PASSPORT. The name on your airfare ticket must match the name listed on your passport or you will not be allowed to travel.

Country of Issurance:*

Passport Expiration Date:

If you must submit a copy of your passport at a later time, please email it to: info.pepaorg@gmail.com.

Date of Birth:*

(MM/DD/YYYY)

Gender*

Spouse's Name:*

If you are married, please enter the name of your spouse here. If not, please enter "N/A".

Your Present Occupation:*

Name of Employer:*

Enter the name of your employer. If not applicable please enter "N/A".

Specialties / Certifications:

French?*

Yes
No
Some Conversational

Blood Type:*

Please enter your blood type. If you do not know it, please enter "UNK".

Special Diet:*

Please enter your special diet, if any. If not please enter "None".

Health Problems / Current Medications*

Please be specific. List all current conditions, ailments and medications that you are currently taking.

Have you ever been charged with a crime or misdemeanor? If yes, please explain. If no, please type N/A:*

Prior international volunteer work? If yes, what countries?*

If not applicable, please enter "N/A".

Do you plan on raising funds to help defray your expenses, or do you intend to pay them yourself?*

Are you prepared to travel distances which would cause a lapse in contact with family and/or business where you cannot be reached for up to 2-3 days?*

Yes
No

How were you referred to PEPA?*

Why do you want to go on this trip?*

Please be as brief and/or specific as possible.

List three recent jobs held and specific skills applicable to this volunteer mission:*

If not applicable, please enter "N/A".

How many previous medical and/or construction trips have you participated in with PEPA?*

List countries, responsibilities, and length of stay of any other missions you have participated in:*

If not applicable, please enter "N/A".

Each volunteer is expected to work under the authority of the team leader(s) and function as a member of a team that will need to adapt to unexpected circumstances. If possible, please give examples of your ability to do this:*

If not applicable, please enter "N/A"

Please provide a personal reference of one individual who would attest to information requested in questions 1-5 (name, address, phone number, email address):*

Please upload a photocopy of valid passport and State Issued ID:

IMPORTANT: Maximum file size is 2MB. If you are unable to submit documents at this time, your file exceeds size limitations, or you have more than one document to submit, PLEASE DO NOT RESUBMIT YOUR APPLICATION. INSTEAD, PLEASE EMAIL THE DOCUMENTS SEPARATELY TO: volunteer@pepahumandignity.org , info.pepaorg@gmail.com . Please include your Names in the subject line of the email.

Comments/Notes:

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Form Submission

Terms and Conditions*

I Agree to the terms and conditions of PEPA NGO