Volunteer Application Form

Family Name: Age

(surename):

First Name: Middle:

Sex (M/F): Nationality:

Address:

City: Country:

Telp: Fax:

Mobile: Email:

Occupation: Employer:

Education:

Availability: ___/___/____ to ___/___/____ Length: ___________days

(dd/mm/yy)

Travel & daily expenses: self-paid / sponsored / no idea

(please circle one)

In Case of emergency, contact person:

Family Name:
(surname):

First Name: Middle:

Address:

City: Country:

Telp: Fax:

Mobile: Email:

Organization Reference:
Organization Name:

Sector (Dept): Leader:

Recomendation:

Signature of Referer:
Name: Date:
My skills:

Languange: English Fluency: fluent / survival

Bahasa Indonesia Fluency: fluent / survival
other:…………. Fluency: fluent / survival

Health condition within the last two years:

Medications currently taking:

Reason of volunteering (50 words max essay):

In consideration of the HOPE worldwide having at my request agreed to allow me to participate in

HOPE Volunteer Corps' activites in Jakarta - Indonesia on ……………………. until ……………………………..

I………………………………(IC No.:……………………) hereby absolve HOPE Worldwide from all liabilities

and indemnity the organization and the organizing committee and keep the organization and the organizing
commintee indemnified at all times from all claims, losses, demands, actions, suits, proceeding, costs and
expenses (including legal costs on solicitor and client basis) whatsover which may be taken or suffered by
the organization or incured or become payable by the organization arising from any injury or accident
(whether fatal or otherwise) to my person or any other person or in respect of any damage or loss to any
of my properties or others which may arise during the course of the HOPE Volunteer Corps activities.

Signature : _______________________________

Name : _______________________________
IC No. : _______________________________
Dated : _______________________________

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Office use - do not fill in:
Pre-approval: By: Date: Approval: By:
qualified / not qualified / not

Assigment Date: