Application Form

GLOBAL VILLAGE APPLICATION FORM

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Required fields are marked with an asterisk (*)

To complete the application form successfully you must have:

Your passport details
Your emergency contact details (next of kin)
Your doctor's details
Your reference(s) details

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

Gender

Date of Birth (dd/mm/yyyy)

Title/Occupation

Company/Organisation

Email Address

Type of Email Address

Home Phone

Mobile Phone

Work Phone

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

Fax

Preferred Phone

HOME ADDRESS

Address 1

Town/City

County

Postal Code

Country

CORRESPONDENCE ADDRESS

(if different from Home Address)

Do you wish to be contacted at a different address?

Address 1

Town/City

County

Postal Code

Country

Address Type

PASSPORT DETAILS

*NB Your passport must be valid for at least 6 months after you have returned home from the trip.

Click here if your passport is or will be expired and please enter your current passport details below

Full Name as on Your Passport

Passport/ID number

Passport Expiry Date (dd/mm/yyyy)

Nationality

GENERAL DETAILS

Do you have any special dietary requirements?

Examples: Vegetarian, Gluten Free, etc.

If yes, please list the requirements below

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?

MEDICAL DETAILS (Confidential)

Please note that the volunteer work assignment will be physically strenuous and mentally challenging and you may wish to consult your doctor about joining a team.

It is necessary that you disclose any illnesses to Habitat for Humanity Ireland as HFH is limited in the support it can offer.

Disclosure of your medical details does not necessarily prevent you from participating in a GV team, however, you will be required to obtain written confirmation from your doctor that you are fully fit to participate in this work trip.

These details will be confidential and only your team leader and appropriate Habitat for Humanity Ireland staff will have access to them.

Any hospital or medical practitioner treating you and not having access to your medical history will need the following information.

Do you or have you ever been diagnosed as suffering from a Mental Health illness?

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 your Blood Group?

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

What is the date of your last Tetanus shot? (dd/mm/yyyy)

Do you wear Contact Lenses?

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

EMERGENCY CONTACTS

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 1

Name

Telephone (Day)

Telephone (Night)

Relationship to You

REFERENCE 2

Name

Telephone (Day)

Telephone (Night)

Relationship to You

MARKETING

Where Did You Hear about Habitat for Humanity?

Other

If your application is successful are you willing to promote your experience through the media?

If yes, please list what media you can do this with.

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 about our work in Ireland and around the world.

Do you wish to opt out of future mailings?

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