Volunteer form
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)