Application for Volunteer

Travel Experience

Name (first, middle, and last)

Home Phone

Work Phone 

Cell Phone 

Home Address

City     State    Zip    

Date of Birth 

Email    Fax   

School Phone (if applicable) 

School Address (if applicable) 

City  State   Zip 

Do you have a passport?

  Yes            No

Name on passport 

Passport #  Expiration Date  

Country of Issue (If USA, Passport Agency)

I am interested in the following area(s) of service:

Medical                                 

Safe Drinking Water/ Well Drilling

Conversational English practice classes (ESI)

Other               Please specify

Please answer the following:

 1.      List any prior experiences you have had which have helped you prepare for this volunteer experience.   Examples may include work experience, volunteer experiences with internationals, teaching experiences, foreign language study and abilities, or related projects, etc.

2.      MEDRIX teams often travel to remote areas of the world where there are potential health hazards and risks, limited hygiene facilities, extreme weather, and very basic living conditions.  What physical limitation(s) may limit your participation under these conditions?

3.      Do you have any other personal considerations that could affect your ability to travel and function in this experience?  

4.      List your interests, abilities, and hobbies.

5.      If you are under the age of 25 and unmarried, please discuss this trip with your parents before submitting this application.  Are your parents supportive?  If not, please discuss your situation with the interviewers when you have your interview.

      Yes                  No

6.      Due to the nature of this work, we need to ask the following question both for your protection and for that of the recipients of this work: 

·        Have you ever been arrested or subject to any criminal investigation or civil investigation related to assault or any abuse of another person? 

No                  Yes

If yes, please specify the circumstances below.

Please email the following to office@medrix.org:

·        One page or less summary of your personal worldview

·        Resume

·        Curriculum Vitae (if applicable)

·        Cover letter stating your qualifications for the specified area of interest you indicated on page 1

Please provide three professional references (business, school, etc): 

1.  Name 

    Address 

    Email Address

    Phone        

    Professional Relationship                                

2.  Name

    Address 

    Email Address

    Phone

    Professional Relationship 

3.  Name 

    Address 

    Email Address

    Phone 

    Professional Relationship                                  
 

In an emergency for (applicant's name) 

please contact:

            Name 

Relationship to applicant 

Address 

City  State Zip 

Home Phone: 

Work Phone:

Health Insurance Company: 

Policy #

Please list Prescription Medications: 

Name of Doctor 

Phone: 

“I certify that I have and will provide information throughout the application process, including on this application for a volunteer position and in interviews with MEDRIX that is true, correct, and complete to the best of my knowledge.  I certify that I have and will answer all questions to the best of my ability and that I have and will not withhold any information that would unfavorably affect my application for a volunteer position.  I understand that information contained on my application may be verified by MEDRIX.  I understand that misrepresentations or omissions may be cause for my immediate rejection as an applicant for a volunteer position with MEDRIX or my termination from such a position if I am selected.”

Signature   Date 

Signature of parent or guardian (if applicant is under 18 years old at time of signature) Date  

When you finish entering your information, please click the Send to MEDRIX button below.  You will be contacted shortly upon receipt of your submitted information.