application

Part I. General Information.
First Name	Last Name
Email	Mobile Phone
Emergency Phone	Work Phone
Home Address	Home Address 2
Home City	Home State	Home Zip
Country/Continent	Name of your Country
Work Address	Work Address 2
Work City	Work State	Work Zip
Please describe how you heard about us.
Best time/dates for you to volunteer?
Please let us know why would you like to volunteer and what would you like to do, to accomplish, or to learn/experience during your time in Madagascar.
Please list your talents, professional interests, skills or other attributes which may be benefitial to the projects.
Please list any previous volunteering experiences
Please list any questions you have for MHI regarding your volunteering and/or any special needs or additional comments you wish to have considered
Part II. A brief background check. (please note that having a negative event in your life's history does not serve as an exclusion from volunteering. However, as random background checks are performed untruthful answers may serve as grounds for denial of your applications.)
Please, answer the following questions/statements:

Immunization history: (please complete all known vaccinations: yes/no & dates)	My last tetanus booster: year ( ) I had diphteria, pertusis (DTP)vac: year ( ) I had measles or vaccine: year ( ) I had rubella or vaccine: year ( ) I had mumps or vaccine: year ( ) I had Hep B vaccine (3x): year ( ) I had Hepatitis A vaccine: year ( ) I had yellow fever vaccine: year ( ) I had Japan.encepheph.vac: year ( ) I had meningococcal vaccine: year ( ) I had Rabies vaccine: year ( ) I had typhoid fever vaccine: year ( )
Tuberculosis and malaria. Please provide us with information about your past history regarding these.	In the past my PPD test was always negative: I had a positive PPD test in the past: If PPD positive, I received prophylactic treatment(INH): year ( ) my last CXR was: year ( ) I've taken malaria prophylaxis before: year ( ) I've had malaria before: year ( ) In the past I could not tolerate (medication):
	I hereby attest that the provided information is true. I understand that I am applying to volunteer to improve the quality of life for vulnerable people. I pledge that I will volunteer in a respectful manner and show dignity toward others. I hereby attest that I will travel and volunteer at my own risk and that I do not intend to hold Maventy Health International responsible for any costs or illnesses which may occur during or after my travels/volunteering.
Please attach your current resume/CV.

Dear MHI volunteer candidate,
Thank you for registering your interest to volunteer with Maventy Health International. Please fill in and submit
the following questionnaire so that we can begin to process your application. Thank you. (estimated time to
complete the application is 15 minutes)

Thank you for taking the time to
apply for a volunteer position with
Maventy Health International.

We will inform you of our decision or contact you
about any questions we might have within seven
(7) days.

Maventy Health International

Volunteer Application

I understand that having a negative past event in my life’s history does not serve as an exclusion from volunteering.	Yes I understand and agree with possible background check	No I do not understand and/or do agree with background check.
I am a law abiding citizen of my country.	yes	no
I have never been convicted of a major crime-like felony.	Yes it is true I have never been convicted of a major crime	NO I have been convicted of a major crime in the past
I do not abuse drugs or alcohol. I do not smoke and am aware of the fire hazard in the villages.	yes it is true I have not abused alcohol or drugs in the past 3 years	No I have abused alcohol or drugs in the past three years
I do not have abusive tendencies or intentions of wrong doing and I plan to be respectful and helpful toward the people I will serve.	Yes it is true I do not have abusive tendencies or intentions of wrongdoing. I plan to be respectful toward the people I work with and-or serve	No I have negative intentions
I do not have a chronic medical condition, past social or behavioral history which could have an impact on my volunteering.	yes it is true I do not have a history of medical condition or past social or behavioral history which could have an impact on my volunteering or interactions with others	No there are factors which may impact my volunteering or may require special accomodation if I am to volunteer with Maventy Health International
If you have answered NO to any of the above questions, please provide detailed explanations.
Part III. ( optional) May be submitted at a later date during the application process. However, if you wish to have your volunteering application process expedited, you may consider providing us with the relevant information.
Note: If accepted, you will likely be volunteering in a territory with higher exposure to communicable & infectious diseases. Please if you can answer the questions about your immunizations to the best of your abilities.