COMMUNICATION FOR HEALTH UGANDA
VOLUNTEER AND INTERNSHIP PLACEMENT APPLICATION FORM (VIPAF)
INSTRUCTIONS TO APPLICANTS:1)This form is to be filled by the intern/volunteer during orientation. Complete this form carefully, print and return the completed form STRICTLY by email to:ccompanied with supporting documents.
2)You may also hand deliver thisapplication form in hard copy format to Communication for Health Uganda Secretariat. If the space provided is not sufficient, you mayuse a separate continuationsheet(s) if necessary.
3)Applications shall be reviewed on a rolling basis dependant on the need. Opportunities are provided solely on individual merit of applicants related to specific intern/volunteer assignment requirements and without regard togender, race, color, religion, national origin, Sexual preference, age, marital status, political affiliation, HIV & AIDS status, disabilityor any other factor that cannot be shown to be relevant to performance.
4)Successful candidates will be informed around within a month upon receipt of the application. Unsuccessful candidates will be notified by email and are encouraged to reapply the following year.
5)You MUSTsubmit your application at least one month before the start of the internship/Volunteership to the attention of Secretary General, Communication for Health Uganda.
6)Incomplete applications may result in delay or non-acceptance.
7)Applicants should submit the following documentation :
- A copy of your Curriculum Vitae/Resume
- Photocopy/ scanned Copy of your valid University/Institutional identity Card
- An introductory letter from the University/Institution introducing you to the agency for internship/volunteer placement with signature and official stamp of the Head of Department in your faculty/college/institute.
- A copy of your full academic transcript/testimonials if any from your current university or higher institution of learningto which you have completed your studies or graduated from earlier or continuing with your studies.
SECTION A: INTERN/VOLUNTEER PERSONAL INFORMATION (In this section, Please Use Capital Letters Only)
Append
recent Photograph / Title: / First Name: / Middle Name: / Surname:
Date of Birth (DD-MM-YYY): / Gender:
Ethnic Origin: / Nationality: / NIN Number:
Marital Status: / Home District: / Postal Address:
Mobile Number (s) / 1. / 2. / Best Time to Call:
E-mail:
Alternative E-mail:
Position Applying for (Tick One) 1). Internship 2). Volunteer
Duration of Intern/Volunteer Placement:
Internship/Volunteer Period: From: / To:
SECTION B: EDUCATION AND QUALIFICATION
YEAR / UNIVERSITY/INSTITUTION / DEGREE AWARD/STUDIES / YEAR OF GRADUATION
SECTION C: SHORT COURSE TRAININGS (Please use a separate continuation sheet if necessary by pressing enter)
Year/Dates / Course/Training Details / Country/Host/Sponsor
SECTION D: LANGUAGES SKILLS
List at least four (4) languages spoken and indicate Excellent, Very Good, Good, Fair, & Poor (Tick as appropriate)
Languages Spoken / Excellent / Very Good / Good / Fair / Poor
SECTION E: COMPUTER SKILLS
List the Computer skills/packages you are familiar/acquainted with for office management
SECTION F: IDENTIFICATION OF TRAINEE (Tick appropriately)
Parent / Student / Individual
Corporate Group / Youth / Others, specify
SECTION G: AVAILABILITY FOR INTERNSHIP/VOLUNTEER SERVICE INFORMATION
What days of the week are you available to work as part of regularly scheduled work week (Tick appropriately)
Monday / Tuesday / Wednesday / Thursday / Friday / Saturday / Sunday
How many hours are you available for internship/volunteer assignment per week? (Tick appropriately)
2 hours / 4 hours / 6 hours
8 hours / 10 hours / 12 hours
1 Week / 2 Weeks / 3 Weeks
1 Month / 2 Months / 3 Months
SECTION H: MOTIVATION AND EXPERIENCE IN INTERNSHIP/VOLUNTEER
Have you previously volunteered with any Non-Government (NGO) or Not-For-Profit (NPO) organization? If yes, please provide the type, name of the NGO, duration of work and brief description of what you did?
Communication for Health Uganda values its people and their passions, not just their qualifications. Using no more than 750 words, tell us a bit more about yourself.What motivated you to apply for internship/volunteer?
Please indicate any previous work experience as a Volunteer/Intern in any other Organization(s):(With contact reference/s if available)
Do you have a specific achievement goal that you plan to accomplish through Internship/Volunteer experience with Communication for Health Uganda? If yes, explain in the space provided.
Briefly describe your special hobbies & Interests
Please explain any expectations and apprehensions (fears and worries) you have concerning volunteering at Communication for Health Uganda
What do you think would be the most challenging aspect of volunteer/internship with Communication for Health Uganda?
Is there anything you would like to work on while on placement or internship with Communication for Health Uganda
SECTION I: REGISTRATION MEMBERSHIP WITH PROFESSIONAL BODIES/ASSOCIATIONS
Name of Professional Body / Level/Type of Membership / Registration Number / Renewal Date
SECTION J: BACKGROUND ABOUT COMMUNICATION FOR HEALTH UGANDA
How Did You Hear Communication for Health Uganda? (Tick appropriately)
Email sent to Us
Referral/Forwarded Email
Web site/Blog site/Internet Advertisement
Others (specify)______
How did you hear about Communication for Health Uganda?
Briefly describe why you want to Intern/volunteer and howyou will benefit by being an intern/volunteer in Communication for Health Uganda (C4HU)
Describe what skills and talents you have that you think would be helpful for Communication for Health Uganda.
Describe what are your strengths and weaknesses and how they will help and harm your time spent at Communication for Health Uganda
Do you have experience in communication?
Communication for Health Uganda (C4HU) may throughout the year collect artwork and comments, take and use photos, videos, tape recordings and or writing of beneficiaries and stakeholders during their activities in the community or field trips. They may be used in print materials, on the web site and social media or in news releases for program and organization purposes.What is your experience in creating multimedia to share your experience with Communication for Health Uganda?
SECTION K:THEMATIC AREAS OF INTEREST AND DELIVERABLES (Tick in the boxes provided)
Social Work & Community Development
Social Researcher
Health
Events Management
Policy, advocacy & engagement
News Letter Production
Volunteer Coordination
Others, specify______
SECTION L: DECLARATION OF CRIMINAL CONVICTIONS (Everyone to Complete)
Please give details on a separate sheet, of all criminal convictions (spent and unspent) including date, offence and sentence. The information you provide will be kept separate and confidential.
Declaring a conviction does not necessarily disqualify you from internship/volunteering with Communication for Health Uganda, but if we later find that you failed to declare a conviction, this will be regarded as gross misconduct, and could lead to your internship/volunteering being terminated.
If you have no Criminal Convictions please write NONE here
and confirm your name and today’s date :
Name Date
The nature of the work for which you are applying will bring you into direct contact with children and young people. Because of this, it is very important you indicate your agebelow. Communication for Health Uganda is committed to the protection of children and we do not employ/work with people whose background is not conducive for working with children. You are required to disclose information about all criminal convictions, both ‘current’ and ‘spent’. All internship/volunteer and employment is conditioned upon successful completion of all background checks, including criminal record checks where possible.
18 – 20 21 – 23 24 – 26 27 – 29 30 – 32 33 – 35 36 – 38+
SECTION M: MEDICAL /HEALTH RECORD
We would like to know if you are psychologically and physically fit to undergo a volunteer or an internship program with Communication for Health Uganda. Indicate yes or no whether you take any of the following drugs and other illegal substance abuse (Tick appropriately).
Type of Illegal Substance / Yes / No
Drug abuse (Marijuana, opium/cannabis, cocaine & mairungi)
Drink Alcohol
Smoke Cigarettes/tobacco
Any, specify
SECTION N: PERSONAL REFERENCES
REFERENCE 1 (MANDATORY)
Name
Position
Organisation
Postal Address
Mobile phone
Work phone
REFERENCE 2 (MANDATORY)
Name
Position
Organisation
Postal Address
Mobile Phone
Work Phone
SECTION O: PERSON TO NOTIFY IN CASE OF EMERGENCY
Name
Relationship
Home District
Postal Address
Mobile Phone Number
Work place Phone Number
SECTION P: EQUAL OPPORTUNITY STATEMENT
As with all appointments across Communication for Health Uganda will adhere to the organisation’s international policies in relation to equal opportunities (available on request). The summary of which sets out that: Communication for Health Uganda will recruit, retain and develop staff, intern/volunteers and Board members from all sectors of the community and will ensure that no applicant or incumbent member receives less favourable treatment on the grounds of gender, race, color, religion, national origin, Sexual preference, age, marital status, political affiliation, HIV & AIDS status, disabilityor any other factor that cannot be shown to be relevant to performance.
Interns/Volunteers should at least be 18 years and above and spend at least 60 hours per weekwith Communication for Health Uganda to qualify for internship/volunteer opportunity.
All information, including the intellectual property rights in any such documents or work conducted, regarding C4HU’s programs and the communities it serves is strictly confidential and property of the organization.
C4HU reserves the right to cancel any such volunteer assignment and association with C4HU in case the relevant policies are not followed by the volunteer. C4HU further reserves the right to cancel such assignment for outstation volunteers provided such cancellation is informed to the volunteers within reasonable time.
The information you provide to Communication for Health Uganda will assist to monitor its equal opportunity policies and to evaluate responses to our internal & external advertising. While the information will also be used for statistical analysis by the organization, no names will be held with those statistics nor will it influence this application process.
SECTION Q: AGREEMENT, SIGNATURE AND CERTIFICATION
By submitting this application, I ______affirm that the facts set forth in it are true, correct, complete and made in good faith. I understand that if I am accepted as an Intern/volunteer, any false or fraudulent statements, omissions, or other misrepresentations made by me on this application may be grounds for NOT giving me internship/volunteer placement or may result in my immediate dismissal after being discovered during placement. I understand that the information I voluntarily provide on or attach to this application may be investigated.
I acknowledge that Communication for Health Uganda will not provide health or accident insurance for my benefit and that I am responsible for providing my own health or accident insurance. I further acknowledge that I am not entitled to and will not receive any employment or workers’ compensation benefits from Communication for Health Uganda. I understand and agree that I will be responsible to pay any and all costs incurred as a result of injury, illness, or death suffered while participating as a volunteer or intern. This acknowledgment and agreement will be binding on me and relatives.
Signature: Date:
Thank you for taking the time to complete all of this information but due to the volume of internship/volunteer placements received, consideration will depend on the need and on the basis of first come first served.
FOR OFFICIAL USE ONLYComments if any:
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Name ______
Designation: ______
Signature: ______Date: ______
All completed forms MUST be returned to the address below.
Communication for Health Uganda
P.O. Box 129, Hoima Uganda
Kwebiha Road, Behind Rukurato Hall
Telephone: (+256) 782688802/703 108383/788664001
E-mail:
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VIPAF Version 01/2017 Volunteer Internship Placement Application Form