Name

Surname

Contact

Email Address

Gender GenderMaleFemale

ID No

Birth Date

Address

Province ProvinceEastern CapeFree StateGautengKwaZulu-NatalLimpopoMpumalangaNorth WestNorthern CapeWestern Cape

Occupation

Employer

First Language

Read Read limited competent fluent

Write Write limited competent fluent

Speak Speak limited competent fluent

Second Language

Read Read limited competent fluent

Write Write limited competent fluent

Speak Speak limited competent fluent

Third Language

Read Read limited competent fluent

Write Write limited competent fluent

Speak Speak limited competent fluent

Fourth Language

Read Read limited competent fluent

Write Write limited competent fluent

Speak Speak limited competent fluent

More Language

Briefly describe yourself (i.e. education, interests, hobbies etc.)

Driver’s License Driver’s License None In Progress A A1 C1 B EB C EC EC1

Physical Limitations? Physical Limitations? Yes No

Explain briefly the physical limitations

Previous volunteer experience?

Any additional information that can assist your application?

Have you ever been convicted / charged of Violation of any laws Have you ever been convicted / charged of Violation of any laws Yes No

Explain violation & treatment

Convicted / charged of abuse against women and children? Convicted / charged of abuse against women and children? Yes No

Explain abuse & treatment

Do you suffer from anger management issues? Do you suffer from anger management issues? Yes No

Explain anger issues & treatment

Do you suffer from Mental illness or substance abuse? Do you suffer from Mental illness or substance abuse? Yes No

Explain mental illness or substance abuse & treatment

Anything else not mentioned above you need to disclose / make us aware of:

Volunteer Programme, please check the boxes you are interested in: Volunteer Programme, please check the boxes you are interested in: Administration Personal assistant Secretary Mentorship Counselling Crisis management Spiritual counselling Events planning Outreaches (other) Fundraising Finance Human resources Communications / Social media Outreaches (workshops/ motivate) Volunteer support staff Community liaison Mental health Physical health Driver Article writing Cleaning / Catering Other

if other, define?

Group Preference(s): Group Preference(s): Children (4 – 11) Adolescents (12 - 18) Young Adults (19 – 21) Adults Geriatrics

Your Availability: Your Availability: Mornings (Mon-Fri) Afternoons (Mon-Fri) Evenings (Mon-Fri) Evenings (weekends) Entire week Once a week One time only As needed Other

Define your availability?

Emergency Contact Name

Relation

Message

Emergency person contact No