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Date of application:Dates of proposed volunteering: / The Centre location:
This form is to be filled out by the Team Leader. Section 1 is personal Team Leader Information and Section 2 is general Team Information. Please also download the Reference Form and have a pastor/church leader and also an employer/educator fill it out with reference to the Team Leader.
Section 1: Team Leader Information
1.1. Personal Details
Name as on passport:Name you prefer/nickname:
Gender: / Passport number:
Date of birth: Day Month Year
Nationality: / Country of residence:
Marital status: Single Married Widowed Separated
If married, name of spouse:
Do you have any children that will be coming with you?
Please state the names, gender, and date of birth of each child:
Occupation:
Address:
Telephone (Home): / (Cell/Mobile):
Skype: / Email:
Contact in case of emergency:
Telephone: / Email:
Address: / Relationship to person:
1.2. English Ability
Is English your first language? / If no, what is?
Speaking: Native Good Fair Poor
Written and Reading: Native Good Fair Poor
What other languages do you speak? Please indicate fluency level:
1.3. Health
If you answer yes to any of the questions below, please give details.
General health: Excellent Good Fair Poor
Do you or your team members currently suffer from any illness, disability or allergy?
Are you or your team members currently taking any medications for any medical condition? If yes, please state condition and medication:
If you feel there are any other specific health issues we should be aware of for you or your team members, please give details:
Please indicate that you and your team will have valid health and/or travel insurance before you travel: Yes No
1.4. Criminal Record
Do you or any of your team members have a criminal record? If yes, please provide details on a separate sheet.
Over the last 5 years have you been investigated, involved with, charged or convicted regarding: drugs, child abuse/molestation, sexual immorality, homosexuality. If yes, on a separate sheet please provide the details.
This this affect your ability to travel to another country?
1.5. Church Affiliation
Home Church:
Address:
Email address: Pastor’s name:
Website:
Positions held in church: Year of salvation:
Year of baptism: Do you tithe to your church?
Please download the reference form and have your current pastor/leader and one other person (not family) will it out and email it back to us as soon as possible.
1.6. Christian Commitment
Please take a few moments to write a short testimony on how you came to Christ (no more than 50 words):
Write a brief description on what you believe your strengths and weaknesses are.
Strengths: / Weaknesses:
Have you or your team members recently (past 5 years) been involved in:
____same sex relationships ___ Eastern religions (Buddhism, new age, wicca, etc)
___ using illegal drugs of any sort ___ Occult activity (such a tarot, transcendental
___ Excessive consumption of alcohol medication, Ouija boards, spirit guides, tc.
1.7. Ministry Involvement
What areas are you interested in being involved in? Please mark as many as you like:
University students
Administration & Human Resources
Other ______/ Teaching, training & equipping
Business consulting
All of the above
Please list your current / past areas of ministry involvement:
1.8. Overseas Missions/Volunteer Experience
List any missions or volunteer experiences you have had:
Location / Time period / Ministry Focus With which organization did
you go?
Section 2: Team Information
2.1. General
What is the ministry strength of team? E.g., teaching English:
Do you require us to set up accommodation?
Intended length of stay (weeks/months/years):
Expected arrival date: / Expected departure date:
Once your application is accepted, please forward a copy of your team flight details as soon as possible.
2.2. Team Member Details
Name / D.O.B / Passport Number / English first language Y/N
2.3. Commitment (on behalf of team)
Will you commit to:
❑ Cooperate with other volunteers, missionaries and national workers.
❑ Comply with Asian Outreach standards and expectations as given in the Information Pack / Staff Handbook.
❑ Work in whatever area your skill set is needed and submit to the leadership of the staff.
❑ Meet all agreed financial obligations for this trip, including cost on the field.
❑ Protect yourself and others from physical and moral hazards.
I declare all information disclosed in this application form to be true and correct. I have not withheld any relevant information. I authorize the investigation of the information contained in this application.
Signed: / Dated:
2.4. Release Statement (by team leader)
Will you please sign the following statement absolving the ministry of all liability during your time as a volunteer. If you are under the age of 16, please get your parents to sign on your behalf.
As a volunteer for The Centre, I hereby release them from any liability or responsibility for injury to me of any kind, including but not limited to, bodily injury, emotional distress, or economic loss, that I may sustain, or may otherwise occur, while I am acting as a volunteer of my own free will.
I voluntarily assume any and all risks of being detained and/or incarcerated by the authorities of the country or countries where I travel while engaged in my voluntary duties on behalf of Asian Outreach. I agree to hold The Centre harmless in all respects if that should occur.
Signed: / Dated:
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Please return to The Centre Chiang Mai by email: or by mail to: The Centre, P.O. Box 177 Chiang Mai University, Chiang Mai 50202 Thailand
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