Habitat for Humanity Ireland Application Form

Required fields are marked with an asterisk (*)

I would like to apply for the Global Village Team trip to:

Are you applying as a*

DESTINATION(S) AND DATES

By indicating this destination I confirm that I am able to travel during the listed dates, and if accepted I commit to being an active member of this team, attending at least three team meetings before the trip and participating fully in team life during the trip.

Destination & Dates (First Choice) *

Destination & Dates (Second Choice)

YOUR DETAILS

First Name*

Last Name*

Date of Birth*

DD

MM

YYYY

Gender*

Title/Occupation

Company/Organisation

Email Address*

Enter EmailConfirm Email

Type of Email Address*

HOME ADDRESS

Address 1*

Town/City*

County*

Postal Code

Country*

Home Phone*

Mobile Phone*

Work Phone

Please leave blank if you do not wish to be contacted at work

Preferred Phone*

Fax

ADDRESS FOR CORRESPONDENCE

(if different from Home Address)

Do you wish to be contacted at a different address?*

Type

Address 1

Town/City

County

Postal Code

Country

PASSPORT DETAILS

*NB Your passport must be valid for at least 6 months beyond the trip return home date.

Full Name as on Your Passport*

Passport Number*

Nationality*

Country your passport is issued by

Passport Expiry Date*

DD

MM

YYYY

GENERAL DETAILS

Do you have any special dietary requirements?*

Examples: Vegetarian, Gluten Free, etc.

If yes, please list the requirements below*

Examples: Vegetarian, Gluten Free, etc.

Do you have a first aid qualification?*

Do you speak any foreign languages?*

Which languages do you speak? How would you describe your ability in each language?*

If you are accepted on this team, are you willing to speak to the media bout your participation in the trip?*

MEDICAL DETAILS (Confidential)

Disclosure of your medical details does not necessarily prevent you from participating in a GV team. Any hospital or medical practitioner not having access to your medical history will need the following information. These details will be confidential and only seen by your team leader and appropriate Habitat for Humanity Ireland staff. Please note that work assignment may be strenuous, and you may wish to consult your doctor about joining a team.

All successful applicants will be required to obtain written confirmation from their doctor that they fully fit to participate in this work trip.

Do you suffer from any allergies?*

Examples: food, medicine, bee strings, etc

Please list the allergies?*

Examples: food, medicine, bee strings, etc

Are you currently taking any medications?*

Please list any medications you are currently taking and the conditions you are taking them for*

Have you had any serious heart, lung, kidney problems or any major illness or surgery in the last 3 years?*

If yes, please give details.*

Do you suffer from epilepsy, asthma, back problems, or other chronic illness?*

Please also list any other medical history which may be pertinent.

If yes, please give details*

Please also list any other medical history which may be pertinent.

Do you have any physical impairment(s)?*

Please give details of any physical impairment(s)*

What is the date of your last Tetanus shot?*

DD

MM

YYYY

What is your Blood Group

If Blood Group is not known it can be given at a later date!

Do you wear Contact Lenses?*

Are you willing to take and pay for all necessary immunisations and anti-malarial medication*

EMERGENCY CONTACTS

All information provided under Next of Kin and Doctor will only be used in case of an emergency.

Next of Kin

Name*

Address 1*

Town/City*

County*

Postal Code

Country*

Home Phone*

Mobile Phone*

Relationship to You*

Doctor

Name*

Address 1*

Town/City*

County*

Postal Code

Country*

Telephone (Day)*

Telephone (Night)*

REFERENCES

Please provide the names of two individuals who can provide a character reference (at least one should know you in a professional context).

Reference One

Name*

Email*

Telephone (Day)*

Telephone (Night)*

Relationship to You*

Reference Two

Name*

Email*

Telephone (Day)*

Telephone (Night)*

Relationship to You*

DECLARATION

By clicking the SUBMIT button at the bottom of this application form:I declare that all the information provided herein is to the best of my knowledge and belief, full, true and correct.

Should any medical issues arise between now and the date of travel, I will disclose this information to the team leaders/Habitat for Humanity.

I understand this is a legally binding document (you may seek legal advice before submitting).

If accepted for a Global Village team, I agree to submit full payment of all costs at the appointed deadlines. I understand that all monies fundraised for the trip must be submitted to Habitat for Humanity Ireland. If for any reason I am no longer participating in the trip, I will submit all donated money to Habitat for Humanity Ireland.

If accepted for a Global Village team, I agree to fulfil the team leaders’ requirements for participation in team activities before, during and after the Global Village trip. I understand that this is a team-based service project and will do my best to make this a positive experience for my fellow team members and the people we meet in-country.

I understand that my place on the team can be revoked at any stage during the preparation for or during the time of the trip if my behaviour is inconsistent with the ethos, requirements or commitments agreed for the trip. If I am involved in any illegal activity or caught in the possession of illegal drugs or weapons during the Global Village trip, I will be evacuated immediately at my own expense.

DATA PROTECTION

Habitat for Humanity Ireland will hold the content of this application on file but will not release the information to any third party (Details will be shared with the team leaders).

From time to time you may receive information from Habitat for Humanity Ireland regarding Global Village opportunities and local builds. If you do not wish to receive these mailings please tick this box.

Do you wish to opt out of future mailings?*

"We believe in a world where everyone has a decent place to live."

Application Form

GLOBAL VILLAGE APPLICATION FORM

DESTINATION(S) AND DATES

YOUR DETAILS

HOME ADDRESS

ADDRESS FOR CORRESPONDENCE

PASSPORT DETAILS

GENERAL DETAILS

MEDICAL DETAILS (Confidential)

EMERGENCY CONTACTS

Next of Kin

Doctor

REFERENCES

Reference One

Reference Two

DECLARATION

DATA PROTECTION