/ INFORMATION: APPLICANT FOR MARIST INTERNATIONAL COLLABORATION WITH- Cmi
To be completed by the HOME PROVINCE responsible for the inscription

Sections – A, B, C & D should be completed and processed before proceeding to Sections E F and final Registration with Cmi

SECTION – A BACKGROUND INFORMATION
01 / PROVINCE DETAILS
This information will be generated automatically and inserted in the data base when the Province Volunteer Coordinator logs in
DATE OF INSCRIPTION / PROVINCE/DISTRICT
PROVINCIAL (or his) DELEGATE / PHONE
EMAIL ADDRESS
02 / PERSONAL DETAILS OF THE APPLICANT
FAMILY NAME/S
GIVEN NAMES
DATE OF BIRTH
SEX / MALE FEMALE
NATIONALITY
MARITAL STATUS
INSERT PASSPORT PHOTO
ADDRESS (Line 1)
ADDRESS (Line 2)
TOWN OR CITY / COUNTRY
POST/ZIP CODE / PHONE
FORMAT: +country code ->number
EMAIL
03 / MOTIVATION, MARIST CONNECTION AND FORMATION
DESCRIBE OR LIST WAYS IN WHICH THE APPLICANT IS A ‘MARIST’
APOSTOLATE | ALUMNUS | VOLUNTEER | TEACHER | EMPLOYEE | FRATERNITY | PARENT | ETC
04 / REFEREES
REFEREE #1 / REFREE #2
NAME OF REFEREE
REFEREE’S OCCUPATION
PHONE NUMBER
EMAIL ADDRESS
RELATIONSHIP TO YOU
REFEREE’S TOWN OR LOCATION
OFFICE USE ONLY / CONTACTED BY
DATE OF CONTACT
SECTION – B DISCLOSURE
05 / STATEMENT OF DISCLOSURE

Marist Mission is always an apostolate with children and young people. Each Province has, or is developing, a Province Child Protection Policy.

A Marist Volunteer is obliged to acquaint themselves with the policies of both the Home and Host Provinces.

A Police/Criminal Check is normal ‘best-practice’ for Volunteer management.

Such a check is obtained from the Volunteer’s home country or the country where he or she has lived if this is appropriate – usually if the applicant has been a foreign resident for longer than one year in recent times.

A Police/Criminal Check is normally required by the host country to fulfil Long Term Visa and Residency or Work Permit requirements.

PRIVACY AND CONFIDENTIALITY GUARANTEE

Information contained all sections [Sections A,B,C,D, E & F] of this form is private and confidential

The hard copy form and the information contained therein is retained by the Province Volunteer Coordinator

Information from the form is entered on the International Data Base using an encrypted web transmission

The computer server holding this information is based at Casa Generalizia, Pzle M. Champagnat, 2 Roma Italia.

The information will be used by Marist Collaboration for Mission International [Cmi] solely for the purpose of facilitating a volunteer placement between the applicant and a Host Community

Has there been any disciplinary or criminal action against you which involved: / ANSWER YES OR NO
  • an act of violence towards another person?
/ YES / NO
  • sexual assault?
/ YES / NO
  • theft or fraud?
/ YES / NO
  • any offence against a minor or adult?
/ YES / NO
  • professional misconduct?
/ YES / NO
Are you aware of any obligations which would prevent you from accepting an invitation to collaborate in Marist mission? / YES / NO
Will you inform yourself and abide by the Child Protection Policies drawn up by the local administrative unit of the Marist Brothers? / YES / NO
Are you willing to apply for a Police or Criminal Check? (in accord with the custom of your home country)
OR do you agree to the Provincial of your Home Province attesting on your behalf? / YES / NO
Police/Criminal Check requested from / DATE:
Does the Province have a copy of the Police/Criminal Check? / YES / NO
In the absence of a Police/Criminal Check is the Province Child Protection Delegate able to certify to the best of his or her knowledge that the applicant is a suitable person? / YES / NO
Has the applicant retained the original Police/Criminal Check or Province certification? / YES / NO
Is there any other personal information that should be known to the Provincial?
NAME OF APPLICANT
SIGNATURE
SECTION – C HEALTH
/ HEALTH ASSESSMENT To be completed by the applicant’s doctor

Personal information remains confidential

06 / IDENTIFICATION
NAME:
D.O.B. / SEX: / MALE FEMALE / Length of time known to the doctor:
BLOOD GROUP: / HEIGHT : / WEIGHT:
07 / HEALTH CHECKLIST

Please check NO or YES then comment on the following (add extra pages if they are required):

All information strictly confidential / Comment if necessary
Existing medical condition/disability/injury / YES / NO
Allergies and Drug Sensitivities / YES / NO
Lung Disorder and Asthma / YES / NO
Blood Pressure Problems / YES / NO
Heart Condition / YES / NO
Nervous Disorder or
Treatment for Mental Health Disorder / YES / NO
Disease or Disorder of Digestive Tract / YES / NO
Cancer (any form) / YES / NO
Disease of the Kidney / YES / NO
Diabetes / YES / NO
Epilepsy / YES / NO
Arthritis / YES / NO
Hepatitis, Malaria and T.B. / YES / NO
Dental Problems / YES / NO
Vision and Hearing / YES / NO
Infectious Disease / YES / NO
Hospitalization over the last one year / YES / NO
Surgical Procedure over the last five years / YES / NO
Family Medical Problems
Prescription or Non-Prescription Drugs
Vaccinations
Signature: / Doctor’s Name:
Email:
Phone Number:
SECTION – D QUALIFICATIONS AND EXPERIENCE
08 / EDUCATION AND TRAINING – University and Technical Education, Trade Qualifications or last year of High School
DATES ATTENDED / INSTITUTION, CITY, COUNTRY / FIELDS OF STUDY OR TRAINING / CERTIFICATE, DIPLOMA OR DEGREE
FROM / TO
09 / NON-FORMAL EDUCATION: ON-THE-JOB SKILLS, CERTIFICATES, LICENSES AND OTHER COMPETENCIES
DATES IFAPPLICABLE / COMPETENCY / HOW ACQUIRED / ANY CERTIFICATES OR LICENSES? IF SO - GIVE DETAILS
FROM / TO
10 / LANGUAGES
LANGUAGE / PROFICIENCY
FIRST / BEGINNER INTERMEDIATE FLUENT
SECOND / BEGINNER INTERMEDIATE FLUENT
THIRD / BEGINNER INTERMEDIATE FLUENT
FOURTH / BEGINNER INTERMEDIATE FLUENT
11 / EMPLOYMENT HISTORY
DATES ATTENDED / ROLE OR POSITION / EMPLOYER / TYPE OF WORK
FROM / TO
12 / VOLUNTEERING AND SOCIAL WORK & COMMUNITY ENGAGEMENT HISTORY
DATES ATTENDED / ROLE OR POSITION / ORGANIZATION / WHO WERE THE BENEFICIARIES?
FROM / TO
13 / OTHER USEFUL INFORMATION
Any relevant information not included in the tables above:
SECTION – E MOBLIZATION AND PLACEMENT
14 / PASSPORT INFORMATION – Details must be EXACTLY the same as in the applicant’s passport
FAMILY NAME
OTHER NAMES
PLACE OF BIRTH / NATIONALITY
PASSPORT NUMBER / COUNTRY
DATE OF ISSUE / DATE OF EXPIRY
15 / APPLICANT’S PREFERENCES
DOING WHAT?
WHERE?
WHEN?
FOR HOW LONG?
16 / EMERGENCY CONTACTS
FIRST CONTACT / SECOND CONTACT
NAME
RELATIONSHIP
ADDRESS (Line 1)
ADDRESS (Line 2)
TOWN OR CITY
COUNTRY
POST/ZIP CODE
PHONE
EMAIL
17 / TRAVEL EXPERIENCE
HOW MUCH TRAVEL EXPERIENCE HAVE YOU HAD? - PLACES, TRANSPORT, STYLE OF TRAVEL ETC.
18 / COUPLES / RELATIONSHIPS/FAMILY
IF THIS APPLICATION IS LINKED WITH THE APPLICATION OF FAMILY OR A FRIEND -
ENTER THEIR SURNAMES
Other relevant information:
SECTION – F COMMUNICATION & PUBLICITY
19 / TEXT OF: APPLICANT’S PROFILE - A PROFILE to be communicated to possible Host Communities
Province Volunteer Coordinators should compose a five line profile of the volunteer. This profile should protect the anonymity of the volunteer but communicate the qualities of the applicant to prospective Host Provinces.
The text will be public [Website, Volunteer Blog and Newsletters] so the applicant should agree to it.
20 / DOCUMENT ATTACHMENTS
The following Documents are likely to be required.
Are they scanned ready for electronic transmission to Cmi and/or the possible Host Community? / Number of Pages
Passport photo page / YES / NO
Travel Insurance policy page with name and number indicated / YES / NO
Air Ticket – electronic ticket / YES / NO
Visa / YES / NO
Degrees, Diplomas and Certificates / YES / NO
Police/Criminal Check [or Provincial certification - or both] / YES / NO
Vaccination Certificates / YES / NO
Medical History if needed for local reference / YES / NO
Other #1 / YES / NO
Other #2 / YES / NO
21 / NOTES AND RECOMMENDATIONS - OFFICE USE ONLY