VOLUNTEER APPLICATION FORM

Please print and post or hand in the application form. Our address is PO Box 20101 in Humewood 6013. You can also email it to us at This email address is being protected from spambots. You need JavaScript enabled to view it. . We cannot wait to meet you!  We ask for R250 to cover costs of a T-shirt, Name Badge and Tea/Coffee in the Volunteers' Lounge. 

 

CONTACT INFORMATION

Title:

ID #:

First name:

Surname:

P. O. Address Line 1:

P. O. Address Line 2:

Suburb:

Postal Code:

Home Phone #:

Work Phone #:

Cell #:

Fax #:

E-mail Address:

Emergency Contact #:

GENERAL INFORMATION

Occupation:

Date of Birth (d/m/y):

Age (16 years & older):

Gender:

Which languages do you speak?

Why are you interested in volunteering at SAMREC?

Do you have any physical restrictions or limitations? (We need to know so that we may accommodate you.)

Do you have any allergies?

Do you take daily medication?

Do you have any special skills?

Do you have a criminal record?

ACTUAL EXPERIENCE

New – No experience

Free feeding

Holding for rinsing

Checking plumage

General cleaning

Washing

Holding for bloods

Admissions

Fish preparation

Rinsing

Readingbloods

Sickbay (ICU)

Force feeding

Holding for washing

Hydration (tubing)

Administration

AVAILABILITY

Weekends: AM or PM Shifts

Weekdays: AM or PM Shifts

Emergencies Situations

Academic Holidays

REFERENCE (Please list one personal or professional reference.)

Name:

Phone #:

Relation:

MEMBERSHIP

I am a member.

I am not a member.

I am interested in becoming a member.

COPY OF ID

All applicants, please enclose a photocopy of your ID.

 

I agree to have a Tetanus injection as I have not recently had one: ___________________

 

I have had a Tetanus injection within the past two years: ___________________________

 

Applicant’s Signature: ___________________  Guardian’s Signature (if applicant is under 21): ________________

 

Signed (day/month/year) _____________________  Witness: __________________________________________

 

·         Please note that volunteers do not receive funds for their time.

·         It is essential that you complete this form in full and return it to the address below.

 

P. O. Box 20101 ·Humewood ·Port Elizabeth ·6013     Tel (27 41) 583 1830     Fax (27 41) 583 2004   

 

VOLUNTEER INDEMNITY FORM

1.                    I, ___________________________________________, the undersigned:

                                     (delete as applicable)

A.              in my personal capacity as a major adult over the age of 21 years;                

B.              in my capacity as guardian of my minor child/dependant

_______________________________________, for and on his/her behalf (“the Indemnity Grantor”),

and pursuant to my/my minor child’s/dependant’s (delete as applicable) application to become a SAMREC volunteer

hereby acknowledge, agree and undertake in favour of SAMREC, its directors, employees, representatives and

agents (“the Indemnified Persons”) that:

1.1                        the Indemnity Grantor is fully aware that the duties of a SAMREC volunteer may involve hazardous

                             activities and the Indemnity Grantor fully accepts all the risks associated therewith;

1.2                        the Indemnity Grantor hereby releases the Indemnified Persons from all liability and holds

                             each and all of the Indemnified Persons harmless against all claims, damages, injuries, losses, deaths,

                             expenses and liabilities arising out of or in any way connected with working as a SAMREC volunteer,

                             including without limitation: 

1.2.1                        any personal injury or loss of life;

1.2.2                        any loss of support, maintenance or other claims or damages

                                 arising from or connected with any personal injury or loss of life

                                 to the Indemnity Grantor;  and

1.2.3                        any loss or damage to clothing or property belonging to the

                                 Indemnity Grantor or any other third party which may occur whilst the

                                 Indemnity Grantor is working as a SAMREC volunteer,

whether arising out of strict liability, statute or otherwise and whether caused by the negligence 

or gross negligence on the part of the Indemnified Persons or any other person or otherwise.

2.                    Each clause of this deed of indemnity is independent and severable from all other clauses.

3.                    The acknowledgements, agreements and undertakings in this indemnity shall be 

                       deemed to be madein favour of the directors, employees, representatives and agents

                       of SAMREC, capable of acceptance at any time.

4.                    Each element of the release from liability and/or indemnity in respect of each cause 

                       or activity covered by this release from liability and/or indemnity shall be separate and severable from the other elements.

5.                    This indemnity shall in all respects be governed by the laws of the

                       Republic of South Africa, and all disputes, actions and other matters arising in connection therewith shall

                       be determined in accordance with such laws.

 

SIGNED (day/month/year)  _________________________________________

 

Witness:                                                                           INDEMNITY GRANTOR

 

__________________________                                    __________________________

Signature                                                                          Signature

 

__________________________                                    ___________________________

Name (print)                                                                    Name (print)