Please fill out the following form:

Section I - Personal Information

First Name:
Last Name:
Date of Birth: / /           Age:
Gender: Male    Female
Mailing Address:
City/State/Zip:
Email Address:
Occupation:
Work Phone:
Home Phone:
Best time to call:
   
Citizenship:
Do You Have A
Valid Passport?		 Yes    No
Passport Number:
   
Program Start Date: / /
Program End Date: / /
Have You Been to Ghana? Yes    No
If yes, indicate
purpose of previous
trip:
   



Section II - Program Placement Information

Level of Education:
Professional Experience:
List previous int'l
travel experience:
   
   
List volunteer
positions in order		 (1)    
of preference:
 		 (2)    
(3)    
Reason for
Volunteering:
How did you hear
about this program?



Section III - Health Information

Blood Type:
Do you have any
medical problems?		 Yes    No
If yes, please
indicate conditions:
Are you under a
physician's care?		 Yes    No
If yes, please
indicate condition(s)
being treated:
Are you currently
taking any
medications?		 Yes    No
If yes, please list
names and reasons
for medication:
Are you on a
special diet?		 Yes    No
If yes, please
indicate the diet:
   
Name, address, &
phone of primary
physician:
   
Name of health
insurance company:
Policy Number:



Section IV - Personal References

(3) References/Phone:
 
 
   
   
  I certify that the information provided in this form is correct.
 




[2005]

   1/02/05 - 1/15/05
   1/15/05 - 1/29/05
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