VOLUNTEER FORM Become a Flame Volunteer Name * First Name Last Name Email Address * Position Applied for Preferred Location Date Of Arrival * MM DD YYYY Arriving From Flight or Bus No. Time of Arrival Hour Minute Second AM PM Pick up on Arrival Yes No Date of Leaving MM DD YYYY No. of Hours per Week No. of Days per Week Gender Male Female Date of Birth MM DD YYYY Place of Birth Nationality Present Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### Passport No. Passport Issue Date MM DD YYYY Passport Issued by Emergency Contact Name First Name Last Name Relationship Emergency Contact Address Address 1 Address 2 City State/Province Zip/Postal Code Country Emergency Contact Tel (###) ### #### Emergency Contact Email Martial Status Single Married If Single and Under 18 Fathers Name First Name Last Name Father Telephone (###) ### #### Father Email If Single & under 18 Mothers Name First Name Last Name Mother Tel (###) ### #### Mother's Email Legal Marriage Certificate Yes No Spouse's Name First Name Last Name Spouse's Occupation Spouse's Company Name Spouse's Phone (###) ### #### Spouse's Email Number of Children Health and Accident Insurance Provider Our goal is for you to have a safe and enjoyable time while visiting/volunteering at Flame Cambodia. In the unlikely event of a medical emergency or accident, Flame Cambodia does not have the resources to manage this situation and therefore the responsibility rests solely with the visitor/volunteer. Insurance Policy No. Other Information Is there anything that we, as your host, should know about that may affect your ability to carry out volunteer tasks or visits to Flame sites (including any physical disability or serious illness)? Note that this can help us prepare for your visit/volunteer assignment. Education Include Start and end dates, Name of Institution, Major Area of Study and Qualification obtained. Other Education Include date of study, insititution and aubject of study Special Interests, Activities and Hobbies Please list any hobbies, activities and special iinterests not already mentioned Khymer Language - Written * Please select your ability level None Basic Advanced Flunet Khmer Language - Oral * Please select your ability level None Basic Advanced Fluent English Language - Oral * Please select your ability level None Basic Advanced Fluent English Language - Written Please select your ability level none Basic Advanced Fluent Other Language 1 Please list the other language Other Language 1 Please select your level None Basic Advanced Fluent Other Language 2 Other Language 2 Please select your ability level None Basic Advanced Fluent Areas of Interest What aspects of Flame are you particularly interested in? Area of Interest Skills What skills and abilities do you have that you would like to use to help Flame? How did you hear about Flame? What interests you most about volunteering with Flame Cambodia? What are your long term goals, and how can volunteering at Flame Cambodia help towards those goals? Flame Beliefs Flame Cambodia is a Christian organization committed to serving the poor and practically demonstrating the love of God. It is not a requirement or assumption that visitors/volunteers are Christians but may be requested from time to time to attend Christian activities organized by Flame Cambodia. As a visitor/volunteer you are representing Flame Cambodia to the communities and clients we work with, and as such we require a standard of behavior that reflects the dignity and respect towards those we work among. We all strive to act in a culturally sensitive manner. Child Protection Policy and Code of Conduct As a child-focused organization, Flame Cambodia is committed to the protection of children. We therefore do not accept visitors or volunteers whose backgrounds are not suitable to work with children. All successful applications are conditional upon the completion of all applicable background checks, including criminal record checks. In the event of any illegal activity or conduct while in country, Flame is absolved from any responsibility. You will be sent our Child Protection Policy and Code of Conduct Policy once we have received this form. Please read and then email the signature page of the Child Protection Policy to info@flamecambodia.org. Please email to info@flamecambodia.org with Volunteer Application in the subject line your Curriculum Vitae and a Police Check or similar document from your country. CV sent Police Check/Criminal Record sent Fees Please note that there are Volunteer fees to be paid to help compensate Flame for the cost of administering your Volunteer assignment. The fee schedule for a visitor/volunteer assignment is USD $45/day per person up to a maximum of USD $200 per person, for up to two weeks. For a group of over four people, the rate is $200 per day. This covers the time and administration expenses of our staff. Transport, food and accommodation are not included in this fee. Details for transport and accommodation options can be provided upon request. The fee is to be paid on arrival at Flame in Cambodia or into the Flame NZ Bank Account. Account Number: 06-0222-0667759-00 Account Name: Flame Cambodia Bank: ANZ Signature * Typing your name in this consititues that you have signed this form and the information you have provided is correct to the best of your knowledge First Name Last Name Thank you! Child Protection Policy
